Mental health articles

Borderline personality disorder treatment plan  Borderline personality disorder (BPD) is
unlike the other personality disorders in that it shows individual and cultural
variations and may improve with age, even without treatment. Typical characteristics of BPD include impulsivity; unstable and intense interpersonal
relations; poorly regulated emotions, including pronounced feelings of
rage, emptiness, and boredom; poor anxiety tolerance; identity disturbance;
self-destructive behavior, including suicide attempts, parasuicidal behaviors,
sexual acting out, and substance abuse; and possible transitory psychosis
(Kernberg, 1984; Linehan, 1993; Stone, 2005).
BPD is the most frequently diagnosed personality disorder (Koeningberg
et al., 1985; Maxmen & Ward, 1995), and certainly is the most common at
college counseling centers. Clinicians may question the appropriateness of
treating BPD on campus on the grounds that these students take too much
of the center’s resources, oft en needing scheduled phone contacts in addition
to weekly sessions to contain their acting-out behavior. Each college center
needs to determine the level of care it can provide to such students. If the
center’s policy is not to do ongoing, long-term work, therapists should make
careful referrals to off -campus providers and fully explain the clinic’s policies.
Otherwise, these students will feel abandoned and may start acting-out/suicidal/
parasuicidal behaviors. If long-term treatment is possible at the counseling
service, supervision and consultations with colleagues are essential to
contain countertransference issues and burnout.

Sharon came to treatment at the insistence of her department chair. A
master’s art student, she was bright, talented, and beautiful. One late
night at the art studio, she was sexually forward with her department
chair, who rejected her advances. Aft erward, she felt so empty and alone
that she took a knife and made shallow cuts on both her arms. Th at next
night Sharon appeared at the chair’s home, crying to his wife about being
rejected “aft er having a special relationship.” When the chair clearly
stated that he had no such special feelings, Sharon again felt betrayed,
threatened to charge him with sexual harassment, and threw a planter
at his head. Th e chair responded by requiring Sharon to get professional
help or else face disciplinary procedures.

Sharon fi t the BPD diagnosis with her self-destructive behavior, angry disruptions
in her interpersonal relationships, impulsivity, and chronic feelings of
emptiness and abandonment. Her prognosis was good, however, as it oft en can
be for college students. Stone (2005) associates the following factors with treatment
success: high intelligence, self-discipline, artistic talent, attractiveness,
and, in cases of substance abuse, the ability to commit to a 12-step recovery
program like Alcoholic Anonymous. Th ese are the very characteristics that
many BPD college students possess.
Students with BPD usually should be assigned to an experienced, senior clinician.
Very close supervision is needed if the therapist is a trainee or new professional,
since students with BPD can sense professional insecurity and may then prematurely leave treatment or feel more out of control and increase their
acting out. All this causes tremendous strain on the counseling center staff in
the form of increased time needed for supervision and crisis intervention.
If the student is being prescribed medication, and the center has enough
resources, the primary therapist probably should be a psychiatrist or psychiatric
nurse. Th e student then has less opportunity to split clinicians (viewing
one as all-good and another as all-bad) and is more likely to take the
medication properly, and the eff ectiveness of the pharmacotherapy can be effi –
ciently monitored. According to Markovitz (2001), because BPD is frequently
accompanied by symptoms like anxiety, depression, psychosis, impulsivity,
hostility, and mood lability, medications like lithium, anticonvulsants, neuroleptics,
and antidepressants can be helpful, the particular medication chosen
depending on the specifi c targeted symptoms.
Clients with BPD who call the center’s on-call crisis counselor should be
asked if they have a primary college therapist and, if so, informed that this
professional will follow up at the next scheduled meeting or sooner if necessary.
Such coordination of care meets the needs of these students, who are
prone to risky behavior.
Dialectical behavior therapy (DBT) and supportive psychodynamic
approaches help with suicidal activity, but their long-term benefi ts are still
unclear (Crits-Christoph & Barber, 2004; Stone, 2005). As with any other client,
ensuring the student’s safety and decreasing self-harm should be the fi rst
step in treatment. Over 70% of patients with BPD have a history of suicide
attempts, and approximately 5–10% actually commit suicide (Livesley, 2003).
Th e current and future risk level for suicide should be carefully determined,
whether through clinical interview techniques or actual suicide assessment
inventories such as the Suicide Probability Scale (Cull & Gill, 1982).
Linehan (1993), in discussing DBT, presents a comprehensive list of factors to
assess the imminent and long-term risk for suicide or parasuicide. Th e therapist
should understand in detail what methods the student would use and the availability
of such methods, and convince the client to remove the lethal means—but
not get into a power struggle if the student is not prepared to comply. Th erapists
should clearly state the desire that students not harm themselves, and emphasize
that therapy does work and that the student’s quality of life can improve.
Th e question of when to hospitalize these students hinges on level of risk.
Reasons for a brief hospitalization include signifi cant risk for suicide or a
serious suicide attempt (which may be induced by a strain in the therapeutic
relationship), the combination of suicidal thoughts and psychoses, and the
need for medications to be stabilized under close monitoring of professionals
(Linehan, 1993).
Th ere are times when considerable risk does not warrant hospitalizing the
student. If so, having someone closely watch the student may provide protection
and decrease feelings of isolation. On the other hand, other students and housing staff have individual and institutional limits. Because they
feel overwhelmed and afraid, sometimes administrators, family members,
roommates, and residential staff put pressure on counselors to hospitalize a
borderline student. Patience is needed. Frequent hospitalizations are not the
answer. It is useful to talk to both the client and other concerned individuals
about the process of treatment, when the therapist should be called, and
when the student should be taken to the hospital. A referral to partial hospitalization
programs in the community is oft en a good alternative to inpatient
stays, giving students necessary structure and intense treatment.
Once life-threatening behaviors have been addressed, the other goals of
treatment are as follows: decreasing behaviors that threaten the process of therapy;
fi xing problems so that there can be a reasonable quality of life; stabilizing
coping skills; resolving posttraumatic stress; and achieving self-validation and
self-respect (Linehan, 1993). Th ese can be achieved by the application of problem-
solving skills, such as identifying target behaviors; generating, evaluating,
and implementing alternative behavior solutions; and using validating strategies
that support the “correctness” of students’ emotions.
Similar strategies are employed by interpersonal and psychodynamic theorists.
Helping the student fi nd a kind, accepting inner voice is essential. Th e
therapist models and mirrors such acceptance and acknowledges the wishes
or desires of the client. In the case of Sharon, her wish to be special and known
was valid and did not warrant shame or embarrassment. However, she had to
fi nd healthier behavioral alternatives to achieve her wish.
Th e psychodynamic literature emphasizes that therapists must maintain
the proper professional distance and closeness, giving support without
rescuing clients; encouraging independence without creating feelings of
abandonment (Maxmen & Ward, 1995). Th is requires the awareness of countertransference
feelings and “staying put”—neither withdrawing nor becoming
aggressive when the going gets tough. Th e idea is that students will give up
their self-destructive behavior when they are able to separate their sense of self
from internalized abusive attachment fi gures (Benjamin, 2004). Th erapists’
task is to validate students’ inner goodness and help them understand their
self-destructive behavior in the context of past and present relations, as well
as in the therapeutic relationship. According to Kernberg (1984), the practice
of diff erentiating self from nonself and confronting students’ tendency to fl uctuate
between idealization and devaluation helps them develop an observing
ego, and so decreases problematic behaviors and thoughts.
Cognitive therapy focuses on students’ dichotomous thinking or maladaptive
schemas. Students with BPD see the world as a scary place where others
abandon or reject them (Sperry, 2003). Th ey oft en jump to conclusions without
proper data. Developing “shades of gray” in their view of themselves and
others leads to more realistic perceptions, better reality testing, and stable
relationships.

Short-term work with BPD students can focus on specifi c relational or situational
problems. Th rough the therapeutic process, Sharon was able to see that
the chair did respect and admire her work. Her ability to trust that he did not
reject her, even aft er she acted out, was critical to the success of treatment.
She learned to contain her rage by verbalizing her feelings rather than acting
them out.

Tags: disorder, Personality Disorder, treatment