[quote=hsieh]
to rnwriter post #29 - yes that is exactly what i'm saying. and as far as making nasty comments about patients - cancer is very difficult to treat and sometimes not curable - but even though cancer is difficult you still don't make nasty comments about people with cancer. that's because you know it's not their fault. when a practitioner makes nasty comments about a diseased person that means the practitioner holds that patient responsible for their disorder.
Cancer patients are usually involved in a collaborative relationship with their clinicians. Everyone is on the same side, fighting the disease together. There are lab tests and tissue slides that give the enemy an identity and provide a way to keep tabs on the progress being made. Even when things are not going well, there is still a good chance that solidarity will prevail.
Borderline personality disorder is exactly the opposite. There is often an adversarial rather than a collaborative atmosphere. Borderline patients have a bleak inner landscape, meaning that they have a very hard time knowing who they are and what they feel
apart from the responses they create in others. They sometimes don't feel that they show up unless they see themselves reflected in someone else's eyes. One surefire way to get a reaction is to provoke the other person. Pick a fight. Break a rule. Challenge a statement. Ask for something inappropriate. This is NOT the norm for cancer patients.
It takes a great deal of patience, energy, and self control to keep from getting sucked in to a borderline patient's vortex. It seems like they are honor-bound to try to pull others into their chaotic world and we are honor-bound to resist. In the thick of the fray, it is all too easy to forget that they aren't choosing to be this way in the way that we normally think of exercising choice.
The negative behavior you have mentioned from mental health practitioners is more complicated than simply holding a patient responsible for their illness. Certainly, that can be a factor, but it's not the only one.
Just as you would like to see the benefit of the doubt extended to borderline patients, it also needs to be given to caregivers, most of whom DO want to provide humane and decent treatment to this most needy of groups. Few of us get up in the morning and say, "Let's go pick on some mentally ill people." The thing is, we are rarely given anything close to the proper tools (training, treatment plans, authority, etc.) to help this highly unresponsive population. And not knowing how to help them or protect ourselves from the emotions they stir up, we do become prone to using black humor and negative stereotyping to try to keep our OWN sanity. I'm willing to bet we'd see a lot less of this stress-generated behavior among caregivers if we understood better what the world looks like to borderline patients AND if we had more effective ways to help them.
This downward spiral consists of:
1) A group of people whose illness includes behavior that irritates and exhausts others, and who resist many treatment options because they have been strongly conditioned by earlier damage to choose rebellion (overt or subtle) over trust in the name of a false sense of self-protection.
2) An illness that cannot be quantified or qualified by lab tests, tissue studies, MRIs, CT scans, or any other objective data. An illness that often masqerades as personality, temperament, culture, attitude, and any number of other attributes that make it look like the person has a direct choice over the way they interact with others. You also have patients who lie, manipulate, coerce, flirt, beg, threaten, and do whatever else they can to get their needs met and keep others off balance because this is how they have learned to feel "safe." Every bit of this is counterproductive to healing. It is also rare to find these behaviors in those afflicted with cancer or other strictly somatic complaints.
3) Practitioners who are discouraged, hamstrung, weary, frightened, enraged, and, most important, human. Borderline patients have a knack for exploiting the caring that family, friends, employers, and clinicians show to them. If help is not offered in very structured ways, it can end up being destructive to everyone involved.
Back to the cancer patients. If a doc or a nurse was dealing with a cancer patient who agreed to follow a particular regimen but skipped appointments, lied about taking meds, exaggerated side effects to invite a sympathetic response, stirred up trouble in the cancer support group, engaged in risky behaviors like going to parties with a compromised immune system, flirted with staff members, asked for inappropriate extra attention, and had excuses for every single problem brought to their attention, you would be very likely to see the same reaction that you judge pretty harshly in the caregivers of borderline patients.
I'd like to ask you, hsieh, what alternative ideas you have for clinicians to help their borderline patients--in practice, not in theory--and still keep their own frustration level in check.
Please answer with a view to clinical situations here and now, not what might happen if these patients were shipped to a third world country. That's another topic which I would like to address in a subsequent post.
Would you like to comment?
