Borderline Personality Disorder: A Care Staff Guide to NICE CG78

Borderline personality disorder, which some services call emotionally unstable personality disorder, is a mental health condition that affects how a person manages emotions, relationships and their sense of self. People with the diagnosis are often among the most stigmatised in health and care services. NICE clinical guideline CG78 sets out how staff should work with them. This guide summarises the main recommendations for care staff.

It is general information, not clinical advice. The NICE guideline dates from 2009, so check the NICE website for the current status and local pathways before relying on any summary.

Do not exclude people because of their diagnosis

NICE says people with borderline personality disorder should not be excluded from any health or social care service because of their diagnosis or because they self-harm. That includes services such as emergency care, mental health teams and community support. If someone you support has been turned away because of their diagnosis, escalate it. Many people with this diagnosis have a history of trauma, and our guide to trauma-informed care explains why that matters.

Building relationships

NICE recommends that staff develop an optimistic and trusting relationship, acknowledging past experiences of stigma and trauma. In practice that means being consistent, doing what you say you will do, and explaining changes in advance. Families and carers should be involved with the person's consent, and services should not withdraw support because they are involved.

Crisis plans

NICE recommends that care plans include a crisis plan. A good plan covers:

• what tends to trigger a crisis
• strategies the person can use to manage it themselves
• how to reach services and who to call
• what staff should and should not do

During a crisis, NICE advises staff to maintain a calm, non-threatening attitude and to try to understand the situation from the person's point of view. Alternatives to admission should be explored before it is considered, and follow-up should be arranged within an agreed timeframe. After the crisis, the plan should be updated to record what helped.

Risk assessment

The guideline asks teams to separate long-term risks from immediate ones, including risks to the person, to others and to dependants. Risk management plans should be shared with the person, and the team's tolerance for risk should be reviewed regularly. NICE stresses a whole-team approach with good supervision, because this work can be demanding. See our guide to suicide and self-harm awareness training for related practice.

Psychological treatment and medicines

NICE says dialectical behaviour therapy should be considered for women where reducing self-harm is a priority. It cautions against brief interventions of under three months outside structured services, and recommends monitoring outcomes such as everyday functioning, substance use, self-harm and depression.

On medicines, the guideline says drug treatment should not be used specifically for borderline personality disorder or its individual symptoms. It advises against long-term antipsychotics, and says short-term sedation in a crisis should be used with caution and for no more than one week. Staff should never advise a person to stop prescribed medicines on their own, but they can flag a review where the person is on many medicines without a clear reason.

Admission and discharge

NICE recommends crisis resolution and home treatment teams before admission, and says admission should be considered only for crises that are very high risk and cannot be managed otherwise, or where the Mental Health Act applies. A formal review is recommended after two admissions in six months. Discharge should be discussed in advance and agreed in a collaborative care plan.

Co-occurring conditions

Many people with this diagnosis also have depression, anxiety, eating disorders or problems with alcohol or drugs. Our dual diagnosis guide explains how to support people with both mental health and substance use needs.

Day-to-day tips for care staff

• Be consistent. Agree boundaries as a team and stick to them kindly.
• Validate feelings. You do not have to agree with how someone sees a situation to accept that it feels real.
• Avoid labels. Words like manipulative can damage trust and close doors.
• Keep records factual. Describe what you saw, not your assumptions.
• Look after yourselves. Reflective practice and supervision protect staff and the person.

Frequently asked questions

Is borderline personality disorder the same as emotionally unstable personality disorder?

They describe the same pattern of difficulties, and different services use different terms. Follow the term used in the person's records and ask them what they prefer.

Can someone recover?

Many people improve over time with the right relationships and treatment. NICE highlights the importance of hope and of not excluding people from services.

Should staff use restraint during crises?

Restrictive practice should be a last resort. Follow your organisation's policy and your training, and focus on de-escalation and the person's crisis plan.

Where can teams find training?

See the CPD hub for professional development options for care and healthcare teams.

Learnsignal will update this guide as NICE guidance changes.