Key priorities for implementation

Key priorities for implementation

Access to services

  • People with borderline personality disorder should not be excluded from any health or social care service because of their diagnosis or because they have self-harmed.

Autonomy and choice

  • Work in partnership with people with borderline personality disorder to develop their autonomy and promote choice by:

    • ensuring they remain actively involved in finding solutions to their problems, including during crises

    • encouraging them to consider the different treatment options and life choices available to them, and the consequences of the choices they make.

Developing an optimistic and trusting relationship

  • When working with people with borderline personality disorder:

    • explore treatment options in an atmosphere of hope and optimism, explaining that recovery is possible and attainable

    • build a trusting relationship, work in an open, engaging and non-judgemental manner, and be consistent and reliable

    • bear in mind when providing services that many people will have experienced rejection, abuse and trauma, and encountered stigma often associated with self-harm and borderline personality disorder.

Managing endings and supporting transitions

  • Anticipate that withdrawal and ending of treatments or services, and transition from one service to another, may evoke strong emotions and reactions in people with borderline personality disorder. Ensure that:

    • such changes are discussed carefully beforehand with the person (and their family or carers if appropriate) and are structured and phased

    • the care plan supports effective collaboration with other care providers during endings and transitions, and includes the opportunity to access services in times of crisis

    • when referring a person for assessment in other services (including for psychological treatment), they are supported during the referral period and arrangements for support are agreed beforehand with them.

Assessment

  • Community mental health services (community mental health teams, related community-based services, and tier 2/3 services in child and adolescent mental health services – CAMHS) should be responsible for the routine assessment, treatment and management of people with borderline personality disorder.

Care planning

  • Teams working with people with borderline personality disorder should develop comprehensive multidisciplinary care plans in collaboration with the service user (and their family or carers, where agreed with the person). The care plan should:

    • identify clearly the roles and responsibilities of all health and social care professionals involved

    • identify manageable short-term treatment aims and specify steps that the person and others might take to achieve them

    • identify long-term goals, including those relating to employment and occupation, that the person would like to achieve, which should underpin the overall long-term treatment strategy; these goals should be realistic, and linked to the short-term treatment aims

    • develop a crisis plan that identifies potential triggers that could lead to a crisis, specifies self-management strategies likely to be effective and establishes how to access services (including a list of support numbers for out-of-hours teams and crisis teams) when self-management strategies alone are not enough

    • be shared with the GP and the service user.

The role of psychological treatment

  • When providing psychological treatment for people with borderline personality disorder, especially those with multiple comorbidities and/or severe impairment, the following service characteristics should be in place:

    • an explicit and integrated theoretical approach used by both the treatment team and the therapist, which is shared with the service user

    • structured care in accordance with this guideline

    • provision for therapist supervision.

    Although the frequency of psychotherapy sessions should be adapted to the person's needs and context of living, twice-weekly sessions may be considered.

  • Do not use brief psychotherapeutic interventions (of less than 3 months' duration) specifically for borderline personality disorder or for the individual symptoms of the disorder, outside a service that has the characteristics outlined in 1.3.4.3.

The role of drug treatment

  • Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder (for example, repeated self-harm, marked emotional instability, risk-taking behaviour and transient psychotic symptoms).

The role of specialist personality disorder services within trusts

  • Mental health trusts should develop multidisciplinary specialist teams and/or services for people with personality disorders. These teams should have specific expertise in the diagnosis and management of borderline personality disorder and should:

    • provide assessment and treatment services for people with borderline personality disorder who have particularly complex needs and/or high levels of risk

    • provide consultation and advice to primary and secondary care services

    • offer a diagnostic service when general psychiatric services are in doubt about the diagnosis and/or management of borderline personality disorder

    • develop systems of communication and protocols for information sharing among different services, including those in forensic settings, and collaborate with all relevant agencies within the local community including health, mental health and social services, the criminal justice system, CAMHS and relevant voluntary services

    • be able to provide and/or advise on social and psychological interventions, including access to peer support, and advise on the safe use of drug treatment in crises and for comorbidities and insomnia

    • work with CAMHS to develop local protocols to govern arrangements for the transition of young people from CAMHS to adult services

    • ensure that clear lines of communication between primary and secondary care are established and maintained

    • support, lead and participate in the local and national development of treatments for people with borderline personality disorder, including multicentre research

    • oversee the implementation of this guideline

    • develop and provide training programmes on the diagnosis and management of borderline personality disorder and the implementation of this guideline (see 1.5.1.2)

    • monitor the provision of services for minority ethnic groups to ensure equality of service delivery.

      The size and time commitment of these teams will depend on local circumstances (for example, the size of trust, the population covered and the estimated referral rate for people with borderline personality disorder).

  • National Institute for Health and Care Excellence (NICE)