I think most of us working in the area would agree that it is a disorder that can always use more ideas in its treatment. I think it is totally necessary to try and get a handle on the worldview of the patient, both as a person with a diagnosis and as an individual. This itself is a difficult enough thing to try to piece together ... let alone to try and find ways to help that person make changes.
My theory is that most of us grow up with a pretty decent foundation - a strong floor beneath our feet. Our parents and others give us that. Sure, all parents muck things up and all of us come out with the occasional hole in our foundation, but we can still stand up most of the time and live our lives.
Borderlines on the other hands have foundations that have TOO MANY holes... the floor beneath their feet resembles swiss cheese and they find it impossible to use this foundation to support them. That is why the world is a chaotic and terrifying place. ANY stressor threatens to throw them into one of the many holes in their foundation. They didn't have the luxury of a firm foundation from their parents...they must learn to build their own.
Most "treatments" for bpd involve trying to fix those holes, however if we as professionals attempt to do that for the person, we are doomed to fail. There are too many, and besides, we can't even SEE them, let alone fix them. Therefore, the key has to lie in helping that person to mend the holes in their own foundations. We give them the tools to do it. But of course, they are terrified. They want to cling to anyone and anything in their world that will stop them falling in. They do not want to venture to the edge of these chasms. They will do almost anything to avoid it -- get angry, avoid, self destruct, manipulate....we've all seen the behaviours.
In order to get well (and yes...some DO get well), EVERY person in their world must stand back and insist that the borderline use their tools and get to work on one hole at a time. Getting to that stage is a long and difficult process, but one of the biggest joys in my life is when I see that person stand with pride and say in effect, "look what I did! I fixed that one! And I did it by myself!"
As practictioners it is our job to:
* give the tools and teach how to use them. DBT, life skills, how to cope with stress, how to cope with trama, how to learn to love yourself, to love and care for others.
* to REFUSE to allow that person to "manipulate" to avoid doing this scary thing.... and I use the term "manipulate" in an understanding way. It is a coping mechanism, just like most of the behaviours we see with BPD.
* Understand the behaviours for what they are - hole avoidance :-) And explain that to the person in a calm and appropriate way, eg: "you smashed your room up because you we afraid to do the work we talked about. I know you're scared, and I understand why you did it. But you still need to do the work. Clean up the mess you made - I am going on a lunch break, and will come and talk to you when you are ready to use your tools. I know you can do it" (smile, squeeze hand, leave room etc)
* be a cheer squad from the sideline - give messages, "I know you are terrified, but I have seen others do it, and I have seen (insert individual strengths) you be strong even though you are scared".
* Reinforce as each "hole" is fixed the achievement they have made and how much easier it is to walk around without fear with each new piece of foundation.
* Don't give up your patient and let them know that. It may take years and many admissions and setbacks while they learn to build their own foundation. With each new admission, remind them of the progress they made last time and remind them that they are here to work some more.... let them know you are looking forward to watching their achievements this time.
Then get to work yourself. Anticipate and cut off the behaviours that avoid the work. Instruct your collegues that your patient is to be directed to you for everything that shift, and make sure she knows that will always be the case. Make regular "appointments" with her (approx 10 mins an hour or two) - snippets of your time and support. Find a system of positive and negative reinforcement that works for that particular person to encourage her to keep working. Eg: a guarantee of safety means some leave to the coffee shop with you. Breaking the fire alarm and absconding into traffic and laying on the road = her time with you is delayed for one hour. Threatening to kill self or harm you = appointment ends immediately. Talking about the feelings surrounding her suicidal ideation or rage = verbal reinforcement and appointment continues.
A few ideas :-)