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The right help at the right time!Treating Borderline Personality Disorder: Getting Off to a Good Startby Edmund C. Neuhaus, PhD, ABPP The most effective, evidence-based treatments for borderline personality disorder (BPD) rely heavily on skills training. Emotion regulation and behavior change are two key treatment priorities. The challenge for many therapists is not knowing how or where to start, especially when a client displays high emotional intensity in the session and may be difficult to “reel in”. It may feel like you’re always reacting to your client and never getting a hold on a course of action. Here are some tips to help you get off to a good start: combine psychoeducation with assessment, validate your client’s experience, and create structure. I’ve learned these tips the hard way: through making mistakes and working through them. And they’ve been tested with clients in the BPD program I started at McLean Hospital/ Harvard Medical School and in my private practice. An accurate assessment is key, but not worth much if I don’t establish a good connection with my client. The combination of psychoeducation and validation goes a long way to establishing a productive and trusting working alliance. As I do my assessment I provide psychoeducation in the process: I frame the problem and offer ways to understand what is going on. For example, poor emotion regulation is a hallmark of BPD; it’s manifested in numerous mood changes throughout the course of a day and week. When I see this pattern, I provide an analogy with the idea of a thermostat connected to the furnace in a house. I describe how a thermostat works to regulate temperature and what happens when it doesn’t work: things heat up until they crash, everything cools down, and you have to start all over again to get the temperature up. Not very efficient for heating your house. I then describe to my client how she does not have an internal thermostat to regulate her emotions. Her life is an emotional roller coaster: emotional temperature goes up, overheats, crashes, cools down, and then restarts. I’ve used this example with thousands of clients and the response is the same: they get it because it makes intuitive sense, plus they feel validated that I know how much they are suffering. This is one of many examples of how to combine assessment with psychoeducation and in the process validate your client’s experience. For more details on this topic, see my webinar series on borderline personality disorder: http://www.atheneumlearning.com/network/cigna/. Create structure. Without structure there is no stability, nor effective treatment. It is essential to create structure in how you conduct sessions, such as setting an agenda, discussing priorities and goals, and teaching specific skills to reach those goals. Not an easy task. In the early stage of treatment, I also find it helpful to focus on my client’s structure in daily life. More often than not, it is haphazard and wrought with emotionally-driven decisions and erratic behaviors. The lack of an internal thermostat gets played out with impulsive decisions, poor planning, and inconsistency with daily routines. To have any chance of helping your client improve emotion regulation, it is necessary to focus on creating a more stable life structure through concrete behavior change, day to day, hour to hour, minute to minute. More details on this can be learned in my webinar series on BPD at http://www.atheneumlearning.com/network/cigna/. No doubt treating BPD can be frustrating and sometimes scary for therapists. With a plan and a clear sense of the priorities of treatment, you have a solid footing to actively move the treatment in a positive direction. |
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Other Featured Articles:Culutural Competency - Increase Quality of Care and Improve Patient Compliance Telephone and Appointmetn Access for 2011 Cigna's 2012 Behavioral Level of Care Guidelines |
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