Borderline Personality Disorder on the Behavioral Unit

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    Folks with Borderline Personality Disorder or BPD can often be a challenge on a behavioral health unit. When dealing with BPD, here are some cognitive-behavioral tips:

    1. Focus on the here and now, not yesterday or the past. The present is all that matters and where it leads to in the immediate future. The present is what placed the person on the unit in the first place. The future allows a way out.

    2. Focus on cause and effect, his/her actions and the resultant consequences. Hold the person accountable for his/her actions (and choices) and how it contributes to his/her current state of unhappiness.

    3. Be objective...always...during your interactions. Lose your objectivity, you pay the consequence of being manipulated now or later by the BPD.

    4. Focus on hope and the ability/courage to change for the better. Most folks actually become empowered knowing that they can eventually beat the odds despite the setbacks...even if the BPD feigns/believes in the hopelessness.

    5. Focus on the self, not on anyone else...externalizing keeps the problem unresolved.

    6. Boundaries, boundaries always. My business has no business in the BPD's business. Codependent staff have the most difficulty with this. Folks with BPD often hone their radar out for codependent folks, be it other patients or staff. When the BPD begins focusing on you, shift it back. Do not become a BPD's victim or his/her escape from his/her reality.

    7. Progress is measured by movement, not by staying the same. It is a forward movement. Staying the same breeds misery. The best progress is slow and planned. Beware of change that happens overnight...rarely does it succeed or last. When it does happen overnight, make a prediction for the BPD that it may fail. Prediction (or to future project consequences) is a powerful clinician tool. It is also a cognitive skill that we wish the BPD to develop as well...so we model it.

    8. Challenge the BPD to improve his/her situation in a positive manner. Do not take NO for an answer. Challenge his/her choices for the better. It provides hope.

    9. Focus on choices and the power in making better choices. Hold the BPD accountable to his/her choices and the actions that follow...for better or for worse. No blaming or externalizing...or poor me's. Keep it objective. The difference between being hopeful and being hopeless is in the cognitive choices we make.

    10. Structure your interactions with a purpose, an agenda to be discussed/resolved. Ambiguity or having an ambiguous interaction will get you nothing but ambiguous results. Ambiguous interactions lead to little or no change and are a general waste of precious time. 1:1s and groups are to have a concrete focus. Place value on the time and on the interactions.

    11. Do not be shaken when the BPD "tests the limits". It is nothing more than a interactional formality of trust for the person with BPD. Expect it to happen...be ready for it...remain objective. When your limits/structures set by you are challenged, it is nothing but the BPD asking "Can I trust you to keep me safe?" Despite the anger or threats by the BPD, the BPD actually comes to respect and trust you more when you do not cave in..."I can trust you, you can keep me safe, even from myself and when I try to manipulate you." For the BPD, the proof is in the pudding.

    12. Educate the BPD to his/her diagnosis. Despite what some may think, it does NOT lead to a self fulfilling prophecy. What it does show to the BPD is that the condition is well known and is easily understood. Assist the BPD to identify his/her criteria that meets the diagnosis and begin problem solving/goal planning away from them. It also helps to keep the BPD objective...a desired goal.

    13. Discuss responsibility with the BPD...but not as a punitive thing. Break it down for the BPD. An easy way is to look at the word itself...Responsibility....aka Response and Ability....that is it in a nutshell. It truly comes down to "being able" to "respond"...in this case, "in getting your genuine human needs met in a better way"...no different from anyone else. This is a good place to introduce Maslow's Hierarchy of Needs. When you use the term Responsibility with the BPD, it is in reference to this. "How have you or what have you done today to get your fill in the blank personal need met?" Irresponsibility is couched in the manner that one has neglected his/her own personal needs, preventing his/her own happiness. If one wants to be happy, meeting one's needs are a requirement. Then tailor this with choices..."we can choose to be happy or unhappy...let's look at your basic human needs." or "No one is responsible for your happiness...but you are. What have you done today to accomplish this?" Give the responsibilty back to the BPD to own...even if he/she chooses not to...it is his/her choice.

    14. Shy away from the victim mentality. Most folks of BPD WERE victims at one time. That is not the problem, however. The problem is that the BPD derives benefits in remaining a victim...and will fight tooth and nail to remain one. Lots of rewards, lots of power, lots of attention are won by it. It is better to focus on being a survivor, moving forward, removing oneself from it. The past holds no hope. The future does. That is the goal...not reliving or replaying the past. Setting boundaries on this is important. You are not to give the past any energy. The past is the road block to genuine progress. If the BPD pulls you back to the past or back to victimhood, redirect and redirect again. If the BPD chooses not to, it is time to close down the interaction. I would be comfortable in saying to him/her that "our purpose together is to see you succeed...and that can only be by moving forward. We can continue to talk about your progress now or get together later."...give the BPD the choice. Always choices, like a broken record. Remember, a victim has no choice. You let the BPD see that you refuse to play the victim game...leaving the choice of victimhood squarely in his/her own lap.

    15. Choices...so important for you to model them for the BPD. A true choice allows you to always choose otherwise. Drawing choice charts are helpful. Choice A leads to additional choices X, Y, and Z. I can also choose not to do Choice A, which leads me to Choice B, which gives me choices D, E, and F. You get the picture. Again, pull the BPD into the head or into the world of cognition. The emotional quagmire and mud keeps the BPD stuck in his/her dilemma...like quicksand. Choices allow hope...emotional angst does not.

    16. Do not fall for the statement "It is my choice to kill myself." This is game playing at its worst and is not a true choice. Remember, a choice always allows you to choose otherwise. Dead is dead...no other choice...therefore, not a true choice. Believe it or not, the BPD knows this...and wishes nothing more than to yank your chain. Don't fall for it...redirect.

    15. Do not reward or give undue attention for misbehavior. During these times, you are to remain the most objective, matter of fact. Address the situation calmly, directly. Do not give the emotional response that the BPD hopes to gain from you. For little misbehaviors/comments, use benign neglect and/or have it be a topic for your 1:1.

    16. For larger misbehaviors, remove the BPD from other patients...do not provide an audience (secondary gain). This can be via time outs/quiet times or via having the BPD perform some structured exercise. Seclusion or restraint is a last resort. Typically when it comes to this, it means the team missed the boat somewhere or didn't intervene early enough...for whatever reason.

    17. During 1:1s, share your honest, objective observations about the BPD's behavior, choices that were present, and progress made. Focus on the positive, but do not lie. The BPD has wonderful radar in picking up dishonesty. If you cannot be congruent in honesty with the BPD during 1:1s, it will come back to haunt you. You may also become a focus of staff splitting later on as a result...for he/she has lost his/her respect and trust for you. Trust and integrity often go hand in hand. So, we have to model that integrity in order to genuinely gain that trust.

    18. Monitor who the BPD gravitates towards...often they seek out other adult BPD's, adolescents (easily to manipulate), Passive Dependent types, and Codependents. Watch for the groupings and groupies. Often times, the BPD forms his/her group to be its leader, to challenge their cause as his/her own. During such, do not address the BPD as its leader...but acknowledge that each person will be addressed individually in time...take the BPD out of that role. The role of the BPD leader is nothing more than another game. It is also a planned distraction by the BPD to not address his/her own stuff on an individual level. Do not be suckered into it. Focus back on the BPD and what personal needs he/she needs to work on...as well as during the next 1:1. BPD's may also gravitate towards Antisocials to either perpetuate his/her victimhood and/or to manipulate them later. Monitor for this as well.

    19. Now, the topic of 1:1s. It is best to schedule your 1:1 with your BPD at the very beginning of your shift...make them first. BPD's are very sensitive to slight. If pushed off to the end, they often interpret this as the other patients having special treatment. Don't play that game. Knock out the BPD 1:1s first if possible...it removes the BPD arguement and game. Structure the 1:1, make it count for something. Very important...objectively announce when the 1:1 time will be over (right off the bat)...and when it ends, it ends. Life does not wait for the BPD, neither do 1:1s. There are time frames. It also helps the BPD to remain focused. Structure what is to be discussed initially...the 1:1 needs to have an agenda...purposeless 1:1s to shoot the breeze are not therapeutic...you can do that on the unit. Make the 1:1 time valuable, focused. Use much of what I have just discussed above. Assign/agree upon homework/practice exercises till the next 1:1...in actuality, it continues the 1:1 past the 1:1 time for the BPD. It also creates an expectation set for the BPD to work on improvements. Come to a collaboration (if possible) in what the next 1:1 topic will be focused on. Have the BPD person feel valued in his/her 1:1 time, especially in the progress made. Always reward positive outcomes and progress in the 1:1. If after the 1:1 the BPD approaches you again for additional 1:1's, inform the BPD that 1:1 time is over for you and that journaling, homework, or making notes to bring for the next 1:1 would be the best option at this time. Embue the 1:1 time as a valuable commodity...something to not waste or to take lightly. Encourage the BPD to bring his/her notes back to the 1:1...it helps the BPD to objectify...very good.

    20. Lastly, treat the BPD as an adult, not as a child...even if it is tempting. An adult BPD acting out like an adolescent is but a game playing role he/she chooses to play. It has also become a comfortable role for him/her...free of responsibility, many secondary gains, a nice distraction from working on the real issues and progress, and allows one to generate and bask in his/her own chaos. It also perpetuates his/her own victimhood. When the BPD plays the child, do not become his/her mom/dad/abuser/et cetera. You remain who you are. You are the nurse, a clinician. Monitor your own speech pattern and tone of voice. Monitor how you are now interacting with him/her...your structural interaction. How has the distance between you and him/her changed? Did you switch into a role easily placed by the BPD?...if you did, you have allowed yourself to be manipulated. Pull back, let another team member handle or end the 1:1, take a time out for yourself, regroup and refocus, and be more mindful the next time during the next interaction. Again, treat the BPD person as an adult, respectfully, honestly, but always objectively. Also, when you treat a BPD like a child, don't complain too loudly afterward when he/she does act this way. You got what you asked for (you structured it or failed to)...treat a BPD like a child, you WILL get childish behavior. You certainly expect better than that...so approach the interaction as one grownup to another. You will eventually get better results. And the BPD will eventually feel better respected as a person by you as well...making improved cooperation possible.

    Remember, BPD is a personality disorder...it took a lifetime to achieve...it will take some time to diminish as a major problem. Most PD's mellow out with age on their own, with maybe Histrionic PD being the exception to the rule. So, until that time of the mellowing, expect acute symptom episodes and hospitalization. Despite this, the progression is certainly impacted by what the person does or does not do for oneself. This is where you come in during the hospital stay...providing the alternatives for a less bumpy road.


    Thunderwolf
    LillyPicadilly, SummitRN, Lambvmd3, and 30 others like this.
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  3. 22 Comments so far...

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    At the request by a member (and from past positive feedback by additional members), I have stuck this post to the top of the forum.
    Jules A likes this.
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    Absolutely great information! Wish I would have had it last week, when a BPD threw the entire unit into a tail spin.
    SDALPN, sharpeimom, and Thunderwolf like this.
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    Thunderwolf,

    You do show some insight but unfortunately you lack insight into the real world, perhaps one day you will be shown this and then i would be truly interested in what advice you then typed.
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    What a great informative article, thankyou!
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    Great article...we've got an influx of borderlines in detox as of late, and it's been trying my patience. At least I'm getting a LOT of experience with dealing with them
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    Vanilla_Sky,

    I thought it was a great post from thunderwolf. What do you mean about in the real world? I have a family member with bpd, and I agree with the post by thunderwolf. I have become very educated about this in the past year. Also, learned that I was co-dependent. Many with family members with bpd do become co-dependent. I had to learn how to set boundaries and limits. Also, made them accountable for their actions. They were very manipulative and manipulated many therapists and even law enforcement. Also, they were good at saying, "I can't help it, I am mental, or you know what sets me off." It is imperative that they are held accountable for their actions.

    Also, they see either all black or all white. Meaning one day, you can be a saint and all good. However, when they disagree with you there is no gray area. You will be painted black and will be their worst enemy. And, then back to being seen as all good again.

    I have learned that DBT is the best therapy. CBT is good, too.
    vintagemother likes this.
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    Hi Thunderwolf

    Great article - thanks muchly. I have just discovered two great theoreticians/clinicians on BPD:


    1. Dawson, D & MacMillan, HL 1993, Relationship Management of the Borderline Patient, Routledge Taylor & Francis Group, New York, NY
    Dawson is really big on the tactic of having the BPD solve her/his own problems by deflecting - "I don't know, Sally. What do you think?" This serves several purposes: not getting the therapist sucked in to the current psychodrama; helps to focus the interaction on the BPD as a competent adult; gives practice in objectifying and thinking through issues etc. Dawson also recommends the use of the uncomfortable silence as a place which encourages what he calls "switching" - where the BPD goes from acting out oppositional and other unhealthy needs to beginning to think how she/he can solve the current problem (empowering). Dawson's key theses are summarised in this article.

    2) Marsha Linehan's work is illuminating in suggesting ways to work with BPDs. Linehan developed dialectical behaviour therapy (DBT). DBT uses validation and dialectical change-based strategies to help BPDs learn new ways of coping. This reading list was developed by Linehan.

    Thanks again for a great primer, Thunderwolf.
    Best wishes
    Trish
    elizabethgrad09 likes this.
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    I thought it was good too. The one thing I do think is important is when you mentioned their victimhood. I think if there are true issues that need to be discussed about a patient's home life or abuse that needs to be discussed in order to resolve it and we should never tell a patient to be quiet or not talk about it if that is what is going to help them through the process. I work at an inpatient psych setting and many of these children/adolescents have come from extremely dysfunctional home, have been abused (emotionaly, sexually and physically). I think they need to get this out.
    I suppose I do have some difficulty being REAL STRICT too. I am a codependent. I am working on it. I think a lot of it has to do with being in girl's home and knowing what it is like to be where a lot of these kids are when I was young. I can relate to many of the patients more than most. I find myself wanting to "rescue" and that is not good. I realize it though and I am learning alot from these sights. Thanks.
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    Excellent advice, ThunderWolf!

    Too many people have trouble understanding that BPD is a different beast than Axis I disorders. All of your tips are spot-on!

    Quote from Shell5
    I think if there are true issues that need to be discussed about a patient's home life or abuse that needs to be discussed in order to resolve it and we should never tell a patient to be quiet or not talk about it if that is what is going to help them through the process.
    I completely disagree - BPDs love nothing more than to talk about these issues, frequently fabricating them. They love to tell heart-rending stories in groups, especially with an audience. They want sympathy, and will say anything to manipulate staff and peers. BPDs require a much more structured treatment plan - the moment they start to talk about past trauma, I shut it down. It sounds harsh, but it's not- it's savvy. On an inpatient unit, they aren't there for therapy about that time they were raped when they were eight - they're there for immediate dangerous behaviors. To talk about anything else is not helpful, outside our scope of practice, and allows them to take the spotlight off of their presenting symptoms.
    Last edit by aura_of_laura on Apr 19, '10


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