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Navigating Boundaries and Building Trust: Clinical Strategies for Working with Clients with Borderline Personality Disorder
This blog post explores evidence-based strategies for addressing BPD and boundaries in clinical practice, offering practical guidance for therapists working with clients diagnosed with Borderline Personality Disorder. It delves into the emotional complexity behind BPD and trust issues, providing actionable tools to help clinicians set compassionate boundaries, navigate therapeutic ruptures, and build lasting relational safety.
Last Updated: May 20, 2025
For many clinicians, working with clients diagnosed with Borderline Personality Disorder (BPD) can present unique relational and emotional challenges. The intensity of emotional expression, rapid shifts in mood, and deep-rooted fears of abandonment often create complex therapeutic dynamics. Yet, with empathy, appropriate boundaries, and consistent therapeutic presence, healing is not only possible—it’s transformative.
According to the National Education Alliance for Borderline Personality Disorder, BPD affects approximately 1.6% of the U.S. population, though some studies estimate it may be as high as 5.9%. It’s often underdiagnosed or misdiagnosed, particularly in minority populations and men. BPD disproportionately impacts women (roughly 75% of diagnosed cases) and frequently co-occurs with other disorders like depression, PTSD, and substance use.
In our Clearly Psyched podcast episode, “Borderline Isn’t a Bad Word,” we explored the stigma that continues to surround BPD and discussed why a strengths-based, compassionate approach matters more than ever. This article distills key insights from that conversation and offers actionable strategies for clinicians supporting clients with BPD.
Understanding the Fear Behind the BPD Behavior
One of the most essential things clinicians must remember is that clients with BPD are often managing deep-seated fear of abandonment and invalidation. What can appear as manipulation or emotional volatility is, at its core, a desperate attempt to maintain connection and safety. The therapeutic task is to interpret these behaviors with clinical curiosity rather than judgment.
Tip: Use phrases like “It sounds like you felt really alone in that moment” or “That sounds painful—thank you for trusting me with it” to validate the emotional experience, even when addressing dysregulated behavior.
Setting Boundaries with Empathy
Clients with BPD often test relational boundaries—not to violate them maliciously, but to see if safety will be withdrawn when limits are expressed. As discussed in the podcast, boundaries must be clear, consistent, and compassionate. They are not punitive; they are protective.
Strategy:
- Be proactive about discussing boundaries at the start of treatment.
- Frame boundaries as tools for maintaining a safe, trusting environment.
- Reinforce that boundaries help sustain the relationship, not end it.
Example language:
"I care about you, and I want this space to feel safe and consistent. That’s why I want to talk through what happens if we miss a session or if communication feels overwhelming."
Struggling to set boundaries with BPD Clients?
Get practical, compassionate language you can use right away to maintain structure and trust in your sessions. Each script models language that blends empathy with clinical clarity, helping you preserve the therapeutic frame while supporting your client’s growth.
Navigating Trust and Rupture
Borderline Personality Disorder is associated with significantly elevated risks of self-injurious behavior and suicide. Research shows that approximately 70% of individuals with BPD will attempt suicide at least once, and about 10% will die by suicide—a risk nearly 50 times higher than the general population.
For you as a clinician, this means maintaining an ongoing focus on safety planning, risk assessments, and collaborative crisis prevention. Incorporating tools such as structured suicide screening, crisis planning worksheets, and safety contracts can not only reduce risk but also build trust through transparency and shared responsibility.
Therapeutic ruptures with clients who have BPD are not uncommon—and they can actually be moments of incredible growth if handled well. A rupture does not mean therapy has failed; it means the client is risking vulnerability in the only way they know how.
Repair Practice:
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Stay grounded and non-defensive.
- Reflect the rupture with curiosity: “Something about what I said didn’t sit right with you. Can we talk about it together?”
- Model emotional regulation and offer collaborative repair.
How to Talk to Someone with BPD
Therapeutic communication with someone diagnosed with borderline personality disorder should emphasize:
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Validation without reinforcing maladaptive behaviors
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Transparency without over-disclosure
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Empathy without enmeshment
Use active listening, attune to nonverbal cues, and avoid sarcasm or dismissive language. Remember, clients with BPD are exquisitely sensitive to perceived rejection.
Enhancing BPD Empathy Through Psychoeducation
Treatment for BPD has come a long way in the last two decades. Among the most well-studied and effective modalities is Dialectical Behavior Therapy (DBT), developed by Dr. Marsha Linehan. DBT focuses on four core skill areas: mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance.
Other evidence-based therapies include:
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Mentalization-Based Therapy (MBT): Helps clients understand their own and others’ mental states.
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Schema-Focused Therapy (SFT): Addresses early maladaptive schemas that drive BPD patterns.
- Transference-Focused Psychotherapy (TFP): Uses the therapeutic relationship to restructure internal object relations.
Integrating these modalities—especially DBT elements—into documentation and treatment planning can help clinicians align with gold-standard care.
Helping clients understand the emotional and physiological roots of their symptoms can be empowering. Psychoeducation helps reframe their experiences and gives language to their pain. Consider sharing diagrams or analogies, like the "emotional intensity thermometer" or the "window of tolerance," to externalize and normalize their reactions.
Cultural Context and Intersectionality
It’s vital to recognize that BPD symptoms—and responses to therapeutic boundaries—can be shaped by culture, race, gender, and lived experience. Emotional expressiveness, trust in authority, and reactions to perceived rejection often vary across cultures. A male client may avoid emotional disclosure due to gender norms. And LGBTQ+ individuals may struggle with identity invalidation on multiple fronts. Clinicians should practice cultural humility, checking their own biases and adapting their communication to honor each client’s narrative. Intersectional awareness deepens empathy and reduces misattunement—key goals in work with BPD.
How ICANotes Supports Clinicians Working with BPD Clients
Clinicians treating BPD often need to document nuanced emotional states, boundary-setting conversations, and interventions around self-harm or suicidal ideation. ICANotes makes it easier by offering:
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Structured yet flexible progress note templates designed for high-risk populations
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Integrated risk assessment tools to track safety concerns
- Customizable treatment planning features that allow you to note attachment issues, interpersonal struggles, and DBT modalities
- Time-saving, menu-driven narrative tools that ensure compliance without sacrificing clinical depth
With ICANotes, clinicians can spend less time typing and more time staying present with emotionally complex clients.
Final Thoughts on BPD, Boundaries, and Trust
Borderline isn’t a bad word—it’s a diagnostic label often wrapped in stigma, misunderstanding, and fear. But behind the label are real people with real pain—and real potential for healing. With boundaries rooted in compassion and a commitment to trust-building, behavioral health clinicians can offer the kind of therapeutic relationship that clients with BPD may never have experienced before.
Let’s keep changing the narrative—one session at a time.
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Dr. October Boyles
DNP, MSN, BSN, RN
Dr. October Boyles is a behavioral health expert and clinical leader with extensive expertise in nursing, compliance, and healthcare operations. With a Doctor of Nursing Practice (DNP) from Aspen University and advanced degrees in nursing, she specializes in evidence-based practices, EHR optimization, and improving outcomes in behavioral health settings. Dr. Boyles is passionate about empowering clinicians with the tools and strategies needed to deliver high-quality, patient-centered care.