The significant increase in community access to psychological services under the Medicare Better Access initiative has led to a growing number of people with Borderline Personality Disorder (BPD) seeking treatment within private practice settings. Unfortunately, this has also led to a rising number of complaints to Council, as psychologists struggle with what can be a very complex presentation.

People with BPD are characterised by marked impulsivity and a pervasive pattern of instability in their interpersonal relationships, self-image and affects (American Psychiatric Association, 2013).  Given the acute and chronic difficulties they experience in important relationships, it should not be surprising that in therapeutic settings, people with BPD can display positive regard and affection towards their psychologists, as well as interpersonal hostility, criticism, rejection and withdrawal (Grenyer, 2012).  With many of the complaints made to Council, the psychologist has struggled to manage their relationship with the person with BPD.  For example:

• The psychologist allows unrestricted email and text contact only to find themselves in a situation where the person with BPD will email and text anywhere up to 50 times per day. Using punitive means to then restrict the amount of contact then unintentionally triggers feelings of rejection and abandonment within the person with BPD leading to the fracture of the therapeutic relationship and eventual treatment failure.
• The psychologists allows sessions to extend significantly beyond the agreed time, sometimes by more than two hours.  When attempts are then made to keep to schedule in following sessions, the person with BPD feels betrayed and abandoned.
• The psychologist allows the person with BPD to sit or lie on the floor of the therapy room or allows them to rest their head on the psychologist’s shoulder or lap, unintentionally creating a belief within the client that their connection is special and goes beyond the typical psychologist-client relationship.
• The psychologists provides frequent and intensive therapy resulting in the accumulation of significant debt and a failure to consider how this financial relationship impacts negatively on the therapeutic relationship.

Many of these complaints have involved very experienced and highly trained psychologists.  Even where there has been an appropriate focus on providing evidence-based strategies and skills for the relief of symptoms, the critical relationship between client and psychologist often has been neglected.  Furthermore, despite the complexity of the presentation, supervision is either not sought or is undertaken with peers who do not have specialist training in the management of BPD. 

Although any complaint is of concern, of more import is the fact that when the therapeutic relationship breaks down, outcomes are poor, often leaving the person with BPD disillusioned with both psychology and their prospects for recovery.  The difficulties faced by health professionals has led to the development and publication of a number of clinical practice guidelines to assist with management of the condition (for example, National Collaborating Centre for Mental Health, 2009; National Health and Medical Research Council, 2012; Project Air Strategy for Personality Disorders, 2015).  Considering some of the key recommendations made by the NHMRC may assist psychologists in providing an effective service for people with BPD and help avoid complaints.  In brief:

1. Psychologists should be able to recognise BPD presentations: Often psychologists fail to realise that they are working with a person with BPD until they are well out of their depth despite the presence of quite obvious signs early in treatment. Psychologists should consider assessing for BPD when a person displays:
   • Frequent suicidal or self-harming behaviour,
   • Marked emotional instability,
   • Multiple co-occurring psychiatric conditions,
   • Non-response to treatment for current psychiatric symptoms, or
   • A high level of functional impairment.
2. Psychologists should be aware of the general principles of care for people with BPD. These include:
   • Effectively gaining trust and managing emotions,
   • Setting boundaries,
   • Managing transitions and endings,
   • Developing a management plan, including a crisis plan, and
   • Assessing and managing risk of self-harm or suicide.
3. Psychologists should be aware of the range of specific effective BPD treatments. Often psychologists provide unstructured, non-evidenced based interventions that have little or no effect. Effective psychological treatments for BPD:
   • Are structured and specifically designed for BPD,
   • Are based on an explicit and integrated theoretical approach,
   • Are provided by a suitably supported and supervised trained psychologist,
   • Focus attention on the person’s emotions,
   • Focus on achieving change,
   • Focus on the relationship between the person receiving treatment and the psychologist, and
   • Consist of regular, typically weekly, therapy sessions.
4. Psychologists should provide appropriate care according to their level of training and skill.
5. Psychologists should refer people with BPD to specialised BPD services when indicated.
6. Psychologists should undertake appropriate continuing professional development.
7. Psychologists should refer families, partners and carers of people with BPD to support services and psychoeducational programs on BPD.

Borderline Personality Disorder is treatable and people with the condition are entitled to receive effective psychological services.  As such, when considering whether to work with a person with BPD, it is important to ask whether you are competent to provide these services, whether you have adequate training in evidence-based treatments for BPD, whether you and/or your service are able to provide a structured intervention, and whether you have access to supervisors with experience with BPD. The answer to these questions will determine whether both you and the person with BPD are kept safe.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Grenyer, B. (2012). The clinician’s dilemma: Core conflictual relationship themes in personality disorders. ACPARIAN, 4, 24-26.

National Collaborating Centre for Mental Health (2009). Borderline personality disorder: treatment and management. National clinical practice guideline number 78. Leicester: The British Psychological Society and The Royal College of Psychiatrists.

National Health and Medical Research Council (2012). Clinical Practice Guideline for the Management of Borderline Personality Disorder. Melbourne: National Health and Medical Research Council.

Project Air Strategy for Personality Disorders (2015). Treatment Guidelines for Personality Disorders 2nd Ed. Wollongong: University of Wollongong, Illawarra Health and Medical Research Institute.

Simon Milton

Professional Officer