Karie was admitted to an adolescent residential treatment facility to treat her self-harm, depression, and borderline personality disorder. She also suffered from diabetes, a disease that requires careful and consistent dietary and medication management. Karie had a history of being unmanageable at home and tended to cut herself when upset. Through the course of treatment it became obvious that she also used her diabetes as a way to self-harm-intentionally failing to comply with her dietary and medication protocol.

The staff watched her very carefully, keeping her within sight and away from objects that she could cut with. But it was harder to control her eating. She manipulated her blood sugar by overeating, sneaking food, and not giving herself enough insulin. Consequently her hemoglobin levels were dangerously high on a regular basis.

If Karie had a difficult interaction during the day, she may later overestimate how much insulin she needed at bedtime, causing her blood sugar to plummet while she slept. Consequently she would wake up in the middle of the night trembling with a blood sugar of 38 (dangerously low). It was easy for her to pass this off as an accident, but over time a pattern developed and it was clear that she used her diabetes as a way to self harm.

Patients with borderline personality disorder are notorious for manipulation. They are very good at making others feel responsible for their choices, and for finding a way around the rules. When combined with the normal adolescent tendency to feel indestructible, it is hard to convince them that taking care of their diabetes is important.

Parents and medical professionals do well to remember that addressing the borderline personality disorder tendencies first is the best way to ensure successful treatment of the diabetes.

Accountability. Have her make a contract indicating what she is willing to do to take care of herself, then hold her to the contract. One of the most important things a young woman with borderline personality disorder can learn is to be responsible for her actions, her interactions, and her health.

Neutrality. Young women with borderline personality disorder often create “love-hate” relationships. They pull people in to get what they want, and push them away if they don’t get what they want. They are very good at blaming others for their poor choices.

The best way to deal with this is to be consistent and, at times, non-emotional. This is not to say that we withhold love. But rather, we present a rational, calm presence that contrasts their dramatic tendencies and does not react to attempts at manipulation. We do not get riled up or sucked into her provocative or dramatic interactions; we are relatively neutral with regard to praise or criticism. We calmly tell her how we feel about a situation and then leave it at that. We demonstrate healthy interactions by verbalizing what we expect from the relationship and supporting these verbalizations with our actions.

Reality. Reality checks are psychotherapeutic technique for working with someone suffering from borderline personality disorder. There are several ways to do it. Role playing with her can help mirror and elucidate her behavior, increasing her self-awareness. You can also help her process options by playing devil’s advocate. Argue all sides of a difficult situation. Over exaggerate the situation to clearly describe what is going on. Create scenarios for all areas; in Karie’s case, this would mean describing scenarios and outcomes and options for cutting and for diabetes mismanagement.

Presence. Do not get caught up in conversations about the future or the past. Conversations become ripe for manipulation and arguments when they are not focused on the present. If a student moves into the future in a futile, despairing, or distracting way, e.g. “my diabetes is never going to go away,” bring the conversation back to the present with, “how are you feeling right now? What can you do about it now? What choice are you going to make now?”

The same suggestion can be applied to focusing on the past. Statements such as, “I’ve never been able to trust anyone,” can be redirected to a more constructive present focus, such as, “who in your life now has shown signs of being trustworthy?”

Boundaries. This may be the most important step in treating someone with borderline personality. Your expectations for her must be explained clearly and then followed through completely. A person with borderline personality disorder may try to get around this by threatening or actually causing self-harm. It is important to be clear about the consequences and to keep her safe without lapsing into caretaking behavior. It is ok to show her care and compassion, but at the same time to maintain clear boundaries and avoid being manipulated.

Expectations must be clear from the beginning for both her therapeutic and medical treatments. Praise her for good behavior and provide the appropriate consequences for negative behavior.

The combined occurrence of borderline personality disorder and long-term physical illnesses like diabetes can prove to be a difficult combination for caregivers. However, addressing the borderline personality disorder in a focused and consistent manner can open the door to more effective medical treatment and, therefore, long-term safety and health.

Megan T. Slater, RN, is a nurse for New Haven Residential Center, part of the InnerChange family of adolescent treatment programs.