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Reducing Non-Compliance in BPD Treatment

The Current State of Borderline Treatment

The typically inflexible nature of borderline personality disorder (BPD) clients is a major limitation to treatment and outcomes.  However, long-term treatment can improve or eliminate symptoms through emotional regulation training, stabilizing their sense of self, and learning how to relate to others. Treatment aiming to achieve these milestones requires self-awareness and acceptance; therefore, certain treatment modalities, including dialectical behavior therapy (DBT) and mindfulness practices, are better suited. While BPD diagnoses are relatively rare in the general population, an astounding percentage of these clients end up in intensive treatment. With nearly 20% ending up in inpatient care at some point in the lifetime of their disorder, and a ten percent suicide rate, effective treatments are an absolute necessity. We know that treatments targeting emotional cognizance and mindfulness are effective, so why are treatment outcomes not as good as we hope? Why is borderline personality order so difficult to treat?

Why Is BPD So Difficult to Treat?

One study asked mental health workers to read vignettes of patients with BPD and major depressive disorder (MDD) then rate their own levels of helping empathy and anger.  The study found that a patient’s perceived control made the workers less empathetic and helpful toward them. Nurses were more inclined to be helpful toward MDD clients than with BPD clients. In general, therapists treating BPD clients report several therapy-interfering behaviors from their clients, such as the volume and time of phone calls, non-collaborative behavior, and premature termination of therapy. According to this research, there are multiple hindrances to treatment. If mental health workers perceive their clients to be in control of their symptoms and therefore are less willing to help, the clients are not receiving the quality of care they need. Treatment options are less available if clients make treatment a near-impossibility, the treatment dropout rate is high, and therapists may be hesitant about treating BPD clients. In addition to mental health workers being hesitant or resistant to providing treatment, BPD clients exhibit non-compliant behaviors in statistically significant levels above the general population. Each component of this treatment barricade may add up to an insurmountable obstacle for BPD clients; as clinicians, this should be a huge concern.

The Most Effective Treatment Scenarios

Certain therapeutic modalities, in conjunction with medication, are more effective for BPD clients than others.  In this list are DBT and mentalization-based treatment (MBT). DBT is often used in PTSD clients, so what makes it so effective for BPD? The first randomized controlled trial for DBT with BPD clients revealed a significant reduction in inpatient stays, parasuicidal behavior, and treatment dropout. The study revealed that skills group training and weekly case management, both components of DBT, achieved the same treatment outcomes. As the goal of DBT is to focus on acquiring skills and shaping behaviors, a treatment that helps clients become more mindful, distress tolerant, able to regulate emotions, and manage relationships helps with the significant sensitivity of BPD clients to invalidating environments. Another clinically significant treatment modality, MBT has proven effective in mitigating BPD clients’ tendencies to assume the motives of others and disconnect from reality. Clients can analyze previous behaviors and put themselves in others’ shoes by mentalizing or imagining real or hypothetical scenarios.  Imagining these scenarios teaches clients to be more flexible and empathetic. While the etiology of BPD remains unclear, we can be relatively certain that unstable attachment throughout childhood contributes to the development of this disorder. MBT was developed to target this vulnerability based on the theory that the capacity to mentalize can mediate sensitivity to non-validating environments. Through these two clinically successful modalities, significant improvement in symptoms and suffering can be achieved.  Yet, clinicians are attempting to practice these treatments worldwide and are still facing the limitations discussed earlier.  How can individual clinicians help their clients remain compliant?

Reducing Non-Compliance One Client at a Time

Compliance varies with a client’s commitment and symptom severity, but there are ways that we can change and improve as mental health care providers.  According to research, here are some ways clinicians can try to reduce non-compliance in BPD clients:
  • Educate everyone who comes in contact with the client about their symptoms and their lack of control. Ensure that all mental health workers are equally as compassionate toward BPD clients as with other clients.
  • Establish non-negotiable boundaries with clients about call volume and work hours.  Respecting these boundaries may help you feel more empathetic toward the client.
  • Be flexible. If one treatment isn’t working for your client, be willing to explore other options. There are more options than just MBT and DBT. Maybe you just haven’t found that light-bulb-inducing combination of treatments just yet.
Treatment outcomes for borderline personality disorder clients are improving every day.  However, the suffering of this population calls for more compassion and grit from their mental health care workers. A full staff of people who understand the symptoms and suffering of BPD clients can improve the quality of care these clients are receiving. Flexibility and boundary-setting can help therapists to stay on the treatment track as well. At Casa Recovery, our highly qualified staff are not only compassionate but are also educated in the suffering of our clients and committed to a positive outcome for them. Our adherence to evidence-based therapies and individual treatment programs will give your client the best chance at making significant gains in symptom management and achieving quality of life improvements. To collaborate with us about treating your BPD clients that puts your client in charge of their mental health, call Casa Recovery at (888) 928-2272.

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