Borderline Personality Disorder (BPD) is characterized by patterns of unstable emotional regulation, disproportionate anger, and intense interpersonal relationships; people who suffer from BPD often experience severe mood swings, impulsive behaviors, and a deep fear of abandonment, which often registers as massive betrayal for which vengeance must be exacted. Due to the fact that BPD sufferers’ behavior will probably seem erratic, extreme and willy-nilly to others, the challenges of treating or interacting with someone who suffers from BPD often seem daunting. As I previously wrote, I find treating or interacting with someone who suffers from BPD analogous to playing chess with someone who has taken LSD. Expect the unexpected.

However, with proper treatment, it is possible for those with BPD to learn to make healthy long-term decisions and mindfully regulate their usually fervid (over-)reactivity.

At the heart of BPD is a profound difficulty controlling one’s feelings. While there may or may not exist genetic proclivities towards afflictions that the DSM characterizes as “Personality Disorders”, I believe that environmental influences such as childhood trauma or emotionally invalidating environments are the primary causes of BPD. For if you believe an affliction is caused or facilitated by genes, then there is very little that talk therapy can accomplish or help solve; however, if you believe that the symptoms of BPD, like the symptoms of OCD, are reactions to environmental situations and trauma (a child’s immature “solutions” to apparent problems), then psychotherapy and treatment methods such as CBT, DBT and EMDR can be extremely helpful.

Patients suffering BPD often report experiencing emotional pain more acutely than others and can become quickly overwhelmed (often dramatically) by their feelings. This emotional susceptibility combined with tendencies towards black-and-white thinking and difficulty trusting others, can lead to tumultuous interpersonal relationships. Also, impulsive behaviors under the guise of immediate coping mechanisms, such as self-harm or substance abuse, may emerge, erupt.

Effective treatment for BPD requires a patient-centered approach WITH STRONG BOUNDARIES. Be compassionate and understanding but with clear limitations — and be aware that the patient is going to try to transgress whatever limitations and boundaries that you establish. You will have bizarre requests made of you that are obviously outside of any therapeutic scope of practice. You will be put on a pedestal and then suddenly denigrated over and over again. You will be Googled and obscure facts about you hidden on the 20th page of any search — like what sport you played in high school — will be casually mentioned in session (knowledge is power). As I previously wrote, the patient is subconsciously (or possibly even consciously) trying to get a reaction out of you.

Thus, your first boundary/limitation is primarily emotional: you must learn to cultivate non-reactivity, especially when the patient turns up the volume and/or heat. When possible, it is best to employ a poker face. Conceive of it as follows: if you react, they “win” — they “win” in their game of trying to get a reaction out of you, to be provocative, to say things that other people would not dare say. Yes, obviously be empathetic, create a safe environment, and have positive regard in order to create trusting, but also be aware that they are going to demean you 100x if they feel at all slighted.

One of the most well-researched and effective treatments for BPD is Dr. Marsha Linehan’s Dialectical Behavior Therapy (DBT). DBT combines Cognitive Behavioral Therapy techniques with mindfulness-based practices to help patients develop skills in emotion regulation, distress tolerance, and mindfulness. In addition to DBT, other evidence-based therapies such as Mentalization-Based Treatment (MBT) and Transference-Focused Psychotherapy (TFP) have also shown promising results. These approaches help patients develop a better understanding of their own mental states, as well as those of the people around them.

Equally important is the role of family and friends in supporting the patient’s recovery. Loved ones should learn how to to set healthy boundaries, validate the patient’s experiences, and encourage the patient to make healthy, long-term decisions based on compassion and love, not spite and vengeance. Support groups, both in-person and online, can also lend solace by providing a valuable sense of community and shared understanding.

With proper support and treatment methods including mindfulness and compassion with strong healthy boundaries, people with BPD can learn to regulate their emotions, curb impulsive behavior, build loving relationships, and lead fulfilling lives.