Q. Dear Dr., I operate a mental health group home staffed by paraprofessionals (some college or none). Could you list a set of guidelines for them in dealing with clients with BPD?
Some are obvious like: give plenty of positive reinforcement for appropriate behaviors; don’t use sarcasm; don’t take criticism personally; maintain structure; etc. Any other suggestions?
This particular client often threatens to leave because she is treated poorly and no one likes her. How should staff respond? She is paranoid and consistently believes others are talking about her or they think she is dirty or has a disease.
A. I deal with a lot of borderlines, and these are the themes I emphasize:
1) The BPD is a MEDICAL problem that they neither asked for nor caused, but they are totally 100% responsible for their behavior. It’s not fair, but it’s the way it is.
2) You can recover and have a happy and healthy life.
3) Treat all patients, borderlines or otherwise with both versions of the Golden Rule: “Do unto others as you would have them do unto you,” and “What is hateful to you do to no other person.”
4) Explain that I won’t stop being their physician because of problems they’re having, but disrespectful behavior towards me or my staff ends our relationship.
5) I explain that many borderlines quit treatment, and when they’re ready to return there won’t be “I told you so” but “lets get moving forward again.”
Regarding your paranoid patient – it could be due to chronic dysphoria, paranoid personality disorder, or paranoid schizophrenia. If it’s just the BPD, one week of prozac followed by tegretol usually stops it.
I would personally tell that patient she’s bringing on a self-fulfilling prophecy (and explain what that means), and that it’s unlikely she’ll see much improvement as long as she chooses to think that way. I don’t “pull punches” with patients – I tell them they become “monsters” under stress, that the disorder has devastated their lives, that they are allergic to alcohol and must never drink again, that they can’t trust any of their bad memories – recent or past, and that the treatment involves both medication and retraining the brain. As Zig Ziglar says: “if you keep on doing what you’ve been doing, you’re going to keep on getting what you’ve been getting” – and it’s corollary: “the definition of insanity is doing the same thing over and over again expecting different results.” I explain what’s wrong (it’s a treatable medical problem that devastates the personality and thought processes), and what needs to be done to have a happy, successful, peaceful life.
It’s important for the health care provider to remember you’re there to help the best you can, not to accept being a victim yourself. It’s also crucial to remember that you are responsible for doing the best you can – to be able to look yourself in the mirror at the end of the day comfortable in the knowledge that you did everything you could do. Don’t judge by outcome, leave that to the patient and God.