alternate ways of treating borderline personality disorder

rn/writer, RN · Jun 26, 2006

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.

hsieh · Jun 26, 2006

my views are different from most of the posts. i learned my views from my workplace. i guess the culture of my workplace views borderline as nothing more than maniputlative drama kings/queens.

StuPer · Jun 27, 2006

hsieh,

I'm sorry to say I find your posts largely lacking in any evidence to back up the ideas/approach you promote, and the idea that sending someone to a 3rd world country will somehow resolve a BPD lacks any basis in reason. You have mentioned they do not have BPD in developing countries, when in fact the reality is they have neither the resources to treat or the means to measure BPD in these countries. So the people who suffer with this personality disorder simply go untreated, they do not simply vanish, the prevalance of BPD in sexually abused children is in the high 70% mark, there is sufficiently rife child sex abuse in many 3rd world countries to establish that BPD does exist in these countries, end of story.

Your suggestion is simliar to a psychological technique that has been found to be traumatic and unethical, that being 'flooding'. A person with a particular phobia is put in an environment where he/she is bombarded with overwhelming ammounts of the subject of their phobia. The theory is that by being exposed to such a situation they will learn that the threat posed by the source of their phobia is wildly over-exagerrated.

In reality people with a BPD have an established set of destructive learnt behaviours (as opposed to fear/anxiety associated with phobias), during the course of the original trauma they learnt these techniques as ways of surviving, and coming to terms with their lives. The only way of treating these traumatised people is by helping them to see there is a better way, that offers greater benefits then their current behaviours. Sometimes it takes many many years for an individual to see past their immediate needs for love/affection/attention before they are capable of attempting DBT. All a clincian can do is offer immediate support and safety management for the current crisis, all the time consistantly telling them they can change their rollercoaster life when they are ready.

So in summary we have BPD clients in developed countries, not because we chose to create the diagnosis, but but we recognise the overwhelming impact of trauma/abuse has on young lives, and we establish resources to help treat people in that situation as an adult. Where as in 3rd world countries where child abuse is often far more prevalent than in developed countries, the issue is not seen as important enough to warrant resources, as they struggle to meet the medical needs of the population, let alone their psychiatric needs.

regards StuPer

cardiacRN2006, ADN, RN · Jun 27, 2006

my views are different from most of the posts. i learned my views from my workplace. i guess the culture of my workplace views borderline as nothing more than maniputlative drama kings/queens.

It seems like you are incapable of answering a direct question. All of us are discussing the subject-with valid points and reasoning. I, for one, would like to hear your answer to rn/writer's simple question.

SilentfadesRPA · Jun 27, 2006

I do not understand the logic of BPD not found in developing nations. I can pesonally tell you that I see a significant population who are immigrants (for immigration physicals ) and find all types of pathology both mental and physical -- Boderlines included -- if significant they are referred for psych clearance.

I think in places of develoment they are not treated, commit sucide (as I have been told) or are just tolerated or shunned depending on thier severity.

I have found several of these post to be on the edge of almost teasing and with no evidence basis to support such findings.

Marc

LydiaNN · Jun 27, 2006

my views are different from most of the posts.

I think this might be the one statement on which we can all agree.

hsieh · Jun 27, 2006

no matter what you believe about bpd the tittle of the thread is alternate ways of treating bpd. one of my co workers at the hosp was beaten, starved, and molested as a child and she is perfectly normal. maybe the key to succesfully treating bpd is to understand how some people are abused as children and grow up to be normal. what can we learn from that population. my co worker says she knew God loved her and she always felt sorry for her parents and even though she was brutalized as a child she says she was a happy child. and as i have said before if child abuse is the prob then it should be renamed child abuse syndrome. as i said in my work culture borderline means manipulative drama kings/queens. how would health care workers react to the label child abuse syndrome? not as bad my guess. part of the prob is we as a nation let down abused children by not punishing child abuser hard enough. for example in vietnam if you molest a child they kill you. we are far to lienient (can't spell) on child abusers. at the long term care facility for the chronically mentally ill that i work at one of the residents is a convicted child molester. i find it odd that management goes to great extremes to make sure he is treated good and his rights are not violated.

LydiaNN · Jun 27, 2006

hseih, honestly we know what the title of the thread is and we know that where you work borderline personality disorder is equated with being a manipulative drama king or queen. Part of the problem with your posts is that when you keep repeating the same information over and over, it is difficult to then respond to your new remarks. I think the idea that changing the dx's name would make a significant difference in the way these patients are perceived is at least as simplistic as the Africa idea. What is the point of thinking outside the box if there isn't also an intention of coming up with workable solutions? Are you suggesting that child abuse become a ''life without parole'' offense? In the most heinous cases, I wouldn't object to that. I do think this society is too lenient on child abusers, and having endured a short stint working in the foster care system, I have stories to prove it. As far as your management going to extremes to protect the rights of your patient, as distasteful as that may be, they are doing what they are legally mandated to do. That's the whole purpose of having ''rights''... if people are allowed to violate them, they don't mean a thing.

hsieh · Jun 27, 2006

i view things as simplistic because you don't have all the time in the world. you only spend so much time alive. when people make things like borderline so detailed and in depth you are wasting time or i should say you run out of time. as dr. phil mcgraw says about therapy if we can't figure this out in 2 days then one of us is a fool.

LydiaNN · Jun 27, 2006

i view things as simplistic because you don't have all the time in the world. you only spend so much time alive. when people make things like borderline so detailed and in depth you are wasting time or i should say you run out of time. as dr. phil mcgraw says about therapy if we can't figure this out in 2 days then one of us is a fool.

Um, yeah, okay. I view borderline personality disorder as complex, because... it is. (edited so as not to be misunderstood...)

Multicollinearity, BSN, RN · Jun 27, 2006

i view things as simplistic because you don't have all the time in the world. you only spend so much time alive. when people make things like borderline so detailed and in depth you are wasting time or i should say you run out of time. as dr. phil mcgraw says about therapy if we can't figure this out in 2 days then one of us is a fool.

Frankly -- I think this thread is pointless now. Nobody is dropping anyone in Africa. Borderline Personality Disorder is complex. This attitude does a disservice to psych patients.

LydiaNN · Jun 27, 2006

Frankly -- I think this thread is pointless now. Nobody is dropping anyone in Africa. Borderline Personality Disorder is complex. This attitude does a disservice to psych patients.

I've got to agree. I've spent a lot of time honestly trying to understand what hseih was getting at, but that last comment was nothing less than alarming. I have to wonder now why it was necessary to start the thread in the first place, since hseih tells us the answer should have been apparent within the first 48 hours.