MHApps BPD – Treatment – Therapy DBT – BPD EUPD GP Health Professional – Options For Effective Treatment
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BPD / EUPD should be thought of as a chronic condition with acute episodes from time to time. Where you start depends on where the patient is at. The priorities are safety and containment, helping them start on the journey to improvement and healing, and then supporting them as they make their way.
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The GP’s task on presentation is to understand and contain the emotional distress, then refer the person to the sort of help they need. The essence of the therapeutic approach to people with BPD / EUPD consists of interventions that are a careful balance of:
- Validation: Support and understanding. Validation is more than “I hear you”. It is truly understanding what is happening for the individual and how they got to where they are now. Your role is as the naïve, empathic inquisitor; and
- Change Message: Your role is as teacher, coach and cheerleader. “While I understand why you do what you do, we have to work on new ways of coping.”
The balanced approach is crucial. If it is validation only, the person becomes bored, stuck, frustrated and still in pain. If it is the change message only, they become resistant, resentful and rebellious.
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There are three common ways in which health workers tend to respond to people with BPD / EUPD. An outline of these follows, along with advice on what is most helpful.
- 1. Enmeshed
Features of this include being over-involved, identification with the ‘victim dimension’, attempts to ‘rescue’ and ‘save’, going beyond the boundaries of the practice, aligning with the patient against other agencies and their boundaries, and solving problems for them. This results in reinforcing their helplessness and distress and encourages dependency. It is not in the long-term best interests of the patient.
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2. Withholding
Features of this include punitive approaches and identification with the ‘perpetrator’ dimension. This connects with verbal and other abuse of the patient. It assumes that they are creating too many problems for the health professional and other services, and services are withdrawn without identifying boundaries and assisting patients in staying within them.
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3. Nurturing and Limit-Setting
This is the most constructive response style and includes: taking care for the patient (not of them); validating their distress; recognising their ability to learn and change; teaching, coaching, assisting, strengthening, and aiding them to help themselves; recognising their existing capacities and reinforcing adaptive behaviour and self-control. There is refusal to take care of them when they can do it themselves; clear identification of the boundaries of the professional relationship; specification of unacceptable behaviours and the consequences for the patient of breaching those boundaries, including enforcing boundaries when necessary; and assisting them to manage their distress and stay within the boundaries.
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In a nurturing and limit-setting framework, new ways of coping can be learned through multi-modal whole person treatment which includes appropriate diagnosis, psycho-education, psychotherapy (individual and/or group), teaching new skills including problem solving, nutrition and exercise, specialised help for substance abuse and eating disorders, and so on.
The outcome being sought through this approach is to put in what society couldn’t give them when they were younger: a knowledge and understanding of their emotions and the capacity to manage them with comfort.
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1. Stabilisation – psycho-education, development of a therapeutic relationship, safety, symptom stabilisation and skill development. (GPs can have a key role in this).
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2. Systematic and titrated uncovering of trauma. (This involves sophisticated therapy, provided by experts only, as the risk of retraumatisation and/or exacerbation of symptoms is high).
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3. Reconsolidation and reconnection. (Time and opportunity to integrate 1 and 2).
Sometimes stabilisation measures are enough for the individual to reconcile the trauma on their own and sometimes not. They will know if they need to address past issues to move towards a healthy and more complete emotional life.
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Whatever the approach, it must be realistic for the individual. Ultimately, the patient must drive the goals, set their own priorities and want to do the work. To be able to do this they need help in understanding what the foundations of their difficulties are. The goals are not, in the first instance, about big picture issues such as "I want a job”, or “I want to be happy". They need to be about "I want to understand how I react and want to change this for the future". Setting modest goals means success can be experienced. Success, no matter how small, can be found if you look hard enough.
If a person commences treatment when they are 16 or 17, it may take only a few months to make significant progress. If they are in their twenties when they start, it can take years.