Community mental health teams
Most people with a borderline personality disorder (BPD) are treated by community mental health teams (CMHTs). The goal of the CMHT is to provide day-to-day support and treatment while trying to ensure that you have as much independence as possible.
A CMHT can be made up of:
- social workers
- community mental health nurses (who have specialist training in mental health conditions)
- counsellors and psychotherapists
- psychologists and psychiatrists (the psychiatrist is usually the senior clinician in the team)
Care programme approach (CPA)
If your symptoms are moderate to severe, you will probably be entered into a treatment process known as a care programme approach (CPA).
A CPA is essentially a way of ensuring you receive the right treatment for your needs. There are four stages:
- assessment of your health and social needs
- care plan, created to meet your health and social needs
- appointment of a care co-ordinator (keyworker), usually a social worker or nurse and your first point of contact with other members of the CMHT
- reviews, where your treatment is regularly reviewed and any necessary changes to the care plan can be agreed
Treatment for BPD usually involves some type of psychological therapy, also known as psychotherapy. There are lots of different types of psychotherapy, but they all involve taking time to help you get a better understanding of how you think and feel.
As well as listening and discussing important issues with you, the psychotherapist can suggest ways to resolve problems and, if necessary, help you change your attitudes and behaviour. Therapy for BPD aims to help people get a better sense of control over their feelings and thoughts.
Psychotherapy for BPD should only be delivered by a trained professional. They will usually be a psychiatrist, psychologist or other trained mental health professional. Do not be afraid to ask about their experience.
It is recommened that patients with BPD should get the following type of treatment:
- treatment that lasts at least 12-18 months
- dialectical behaviour therapy for people who really struggle with self-harming behaviours
- mentalisation-based therapy, which is a mixture of group and individual reflection
- therapeutic communities and structured group therapy programmes
These therapies are described below.
There is no evidence that any other types of therapy are particularly helpful. If you have a history of sexual abuse in childhood, it may not be a good idea to start with individual work, which can be upsetting. It may be better to start in a group and learn to manage horrible feelings safely before doing individual work.
The psychotherapy you choose may be based on a combination of personal preference and the availability of specific treatments in your local area.
Dialectical behaviour therapy (DBT)
Dialectical behaviour therapy (DBT) is a type of therapy that has been specifically designed to treat people with BPD.
DBT is based on the idea that two important factors contribute towards BPD:
- You are particularly emotionally vulnerable, for example low levels of stress make you feel extremely anxious.
- You grew up in an environment where your emotions were dismissed by those around you. For example, a parent may have told you that you had no right to feel sad or you were just 'being silly' if you complained of feelings of anxiety or stress.
These two factors may cause you to fall into a vicious circle. You experience intense and upsetting emotions, yet feel guilty and worthless for having these emotions. Because of your upbringing, you think that having these emotions makes you a bad person. These thoughts then lead to further upsetting emotions.
The goal of DBT is to break this cycle. This is done by introducing two important concepts:
- validation: accepting that your emotions are valid, real and acceptable
- dialectics: a school of philosophy that says most things in life are rarely 'black or white' and it is important to be open to ideas and opinions that contradict your own
The DBT therapist will use both concepts to try and bring about positive changes in your behaviour.
For example, the therapist could accept (validate) that feelings of intense sadness cause you to self-harm, and that behaving in such a way does not make you a terrible and worthless person.
But then the therapist would attempt to challenge the assumption that self-harming is the only way to cope with feelings of sadness.
The ultimate goal of DBT is to help you 'break free' of seeing the world, your relationships and your life in a very narrow, rigid way that leads you to engage in harmful and self-destructive behaviour.
DBT is made up of four components:
- weekly individual sessions, in which you discuss ways you can help control and improve your behaviour
- weekly group sessions, where you interact with other people with BPD as well as a number of different therapists and discuss ways you can all improve your emotional control and your relationships with others
- out-of-hours telephone contact, where you are given a contact number for your therapist so you can speak to them if you have a crisis (severe worsening of your symptoms)
- a therapist consultation group, which does not involve you directly, but where the therapists discuss issues that may have arisen with the treatment of their clients (you should not see this as the therapists 'talking behind your back')
DBT is based on teamwork. You will be expected to work with your therapist and the other people in your group sessions. In turn, the therapists work together as a team, and the consultation group is part of the process.
There are four main stages in a course of DBT:
- stage 1: helping you control your behaviour and refrain from self-destructive and harmful behaviour
- stage 2: helping you tolerate your negative emotions while also experiencing positive emotions more fully
- stage 3: helping you focus on difficulties affecting your everyday life
- stage 4: helping you gain more happiness and joy out of your everyday life
It is not necessary to complete all stages to combat the symptoms of BPD.
Also, due to a lack of trained therapists, many primary care trusts only provide the first stage of treatment free of charge on the NHS. If you wish to receive the entire course, you may have to pay a fee.
DBT has proved particularly effective in treating women with DPB who have a history of self-harming and suicidal behaviour. It has been recommended by the National Institute for Health and Clinical Excellence (NICE) as the first treatment for these women to try.
Mentalisation-based therapy (MBT)
Another type of long-term psychotherapy that can be used to treat BPD is mentalisation-based therapy (MBT).
MBT is based on the concept that people with BPD have a poor capacity to mentalise.
Mentalisation is the ability to think about thinking. This means examining your own thoughts and beliefs, and assessing whether they are useful, realistic and based on reality.
For example, many people with BPD will have a sudden urge to self-harm and will then fulfil that urge without questioning it. They lack the ability to 'step back' from that urge and say to themselves, 'That is not a healthy way of thinking and I am only thinking this way because I am upset.'
Another important part of mentalisation is to recognise that other people have their own thoughts, emotions, beliefs, wishes and needs, and your interpretation of other people's mental states may not necessarily be correct. In addition, you need to be aware of the potential impact your actions will have on other people's mental states.
For example, a person with BPD meets a close friend for lunch because that friend has recently lost her grandmother. But during lunch, the person with BPD spends the entire time talking about their problems. So the close friend leaves abruptly as she is fed up of being ignored and not receiving the emotional support she was expecting.
This causes the person with BPD to fly into a rage at what they perceive to be a snub. They lack the ability to recognise that their friend has their own set of emotional needs and that their actions had a negative impact on their friend.
The goal of MBT is to improve your ability to recognise your own and others' mental states, and learn to 'step back' from your thoughts about yourself and others and examine them to see if they are valid.
Initially, MBT is usually delivered in a hospital, where you would stay as an inpatient. The treatment usually consists of daily individual sessions with a therapist and group sessions with other people with BPD.
The therapist will work with you by asking you questions and setting tasks that encourage you to mentalise.
A course of MBT usually lasts around 18 months. Some hospitals and specialist centres encourage you to remain as an inpatient during this time. Other hospitals and centres may recommend that you leave the hospital after a certain period of time but remain being treated as an outpatient, where you visit the hospital regularly.
Therapeutic communities (TCs)
Therapeutic communities (TCs) are structured environments where people with a range of complex psychological conditions and needs come together to interact and take part in therapy.
TCs are designed to help people with long-standing emotional problems and a history of self-harming by teaching them the skills needed to interact socially with other people.
Most TCs are residential, such as in large houses, where you stay for around one to four days a week.
As well as taking part in individual and group therapy, you would be expected to do other activities designed to improve your social skills and self-confidence, such as:
- household chores
- meal preparation
- games, sports and other recreational activities
- regular community meetings, where people discuss any issues that have arisen in the community
TCs are run on a democratic basis. This means that each resident and staff member has a vote on how the TC should be run, including whether a person is suitable for admission to that community.
If your care team advises that you may benefit from spending time in a TC, it does not automatically mean the TC will allow you to join.
Many TCs set guidelines on what is considered acceptable behaviour within the community, such as no drinking alcohol, no violence to other residents or staff, and no attempts at self-harming. Those who break these guidelines are usually told to leave the TC.
While some people with BPD have reported that the time spent in a TC helped their symptoms, there is not yet enough evidence to tell whether TCs would help everyone with BPD.
Also, because of their often strict rules on behaviour, a TC would probably not be suitable for you if you were having significant difficulties controlling your behaviour.
Treating a crisis
You will probably be given several telephone numbers to use if you think you may be experiencing a crisis (when symptoms are particularly severe and you have an increased risk of self-harm).
One of these numbers is likely to be your community mental health nurse. Other numbers may include an out-of-hours number for social workers and your local crisis resolution team (CRT).
CRTs treat people with serious mental health conditions who are currently experiencing an acute and severe psychiatric crisis, which would require hospitalisation without the involvement of the team. An example of a severe psychiatric crisis would be a suicide attempt.
Often, people with BPD find that simply talking to somebody who understands their condition can help bring them out of a crisis.
In a small number of cases, you may be given a short course of medication, such as a tranquiliser, to calm your mood. This medication is usually prescribed for seven days.
If your symptoms are particularly severe and it is thought that you pose a significant risk to your own health, you will be involuntarily detained under the Mental Health Act at a secure mental health facility. This will be for as short a time as possible, and you should be able to return home once your symptoms have improved.