alternate ways of treating borderline personality disorder

[hsieh]

this thread is made to discuss and debate alternate ways of treating borderline personality disorder. the point is to "think outside the box" and "stirring the pot" is also acceptable and encoraged. please respond to subject only and not the specific member who is posting the subject. for example if somebody says - i think the world is flat - please do not respond with - the reason you think the world is flat is because you're an idiot. i can't wait to read other's ideas of alternate ways to treat boderline personality disorder. let the posting begin.

[rn/writer, RN]

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.

People don't "make" borderline personality disorder "detailed and in depth." It IS a complex disorder, in part, because is has become a catch-all phrase that covers many variations and degrees of dysfunction.

To come up with a one-size-fits-all treatment plan is foolhardy and dangerous. And it points to the very same impatience that you refer to with such distaste in your co-workers. They deal with their frustration by referring to the patients with disrespect and calling them drama kings and queens. You deal with yours by bringing up an impractical solution like shipping them to a third world country, an idea that shows insensitivity to both the patients AND the country you're proposing they be sent to.

I was sympathetic to your posts initially. I thought that you were saying that the present system is far too enabling of disordered behavior and has proven largely ineffective. I can't argue with either of those thoughts. I also agree that it's wrong (though I do believe understandable) for staff members to negatively label their patients and dismiss their complaints as nothing more than manipulation and dramatics.

It seemed that you were holding out for bpd patients to be viewed with more respect and given more effective treatment. Both are admirable goals.

Now, I'm beginning to question your basic understanding of borderline personality disorder. And the amount of respect YOU have for those so afflicted.

You speak of renaming bpd "child abuse disorder" so that it can be taken more seriously and staff members will not be tempted to dismiss the patients' acting out and other symptoms as just so much drama. While child abuse is often a component of a bpd patient's history, it is hardly universal. There are many patients who grew up in fairly stable homes who were not beaten, molested, or tormented, who still somehow end up as dysfunctional as the next bpd patient. And, as you pointed out, there are those like your friend, who come through a wicked past without becoming warped by it.

I say all of that to say that renaming bpd "child abuse disorder" so that the patients will invite a more sympathetic response is inaccurate, misleading, and simplistic. What we need is a better overall understanding of bpd itself and what the world looks like to these patients along with treatment options that actually accomplish something. Increased empathy and effective treatment strategies will do much to render staff more capable and caring.

Although some might disagree, bpd IS (at least functionally) a developmental disorder. If you doubt that, take a look at any normal two- or three-year-old child and compare them to an adult borderline patient. What you will see are boundary issues, self-centered thinking, distrust, mistrust, a long list of fears, an exaggerated quest for autonomy, diminished or absent empathy, appetite-driven actions, obsessive attachments, great impatience, hypersensitivy/insensitity confusion, and a host of other intense needs and desires.

What is normal (and sometimes even cute) in a toddler is problematic and disturbing in an adult. And while toddlers are, by definition, limited in the amount of damage they can do, adults are often free to wreak havoc on themselves and everyone around them. Because they are dependent and pretty well confined, toddlers are much more amenable to "treatment" than your average adult bpd patient. That is to say, a combination of nurturing, consistent limit-setting, and short-term posititve and negative consequences can help a toddler to safely move forward into the next level of maturity. Being dependent, they don't have many options to resist.

Somehow, for whatever reason, these bpd folks got left behind. And now, because they are chronological adults, they have rights and access to all kinds of "goodies." They are emotional toddlers with car keys and checkbooks. They can legally enter into binding contracts (including marriage) without anything close to a real understanding of the significance of their actions. One motto for the severely bpd might be, "It seemed like a good idea at the time." Another might be, "It wasn't my fault," followed by a catalog of excuses and extenuating circumstances.

If you look at Erickson's developmental stages, you will see that the first two--trust and autonomy (the ability to recognize one's self as an individual) cover the first three years of a child's life. If these stages are messed up, you will end up with a child who trusts when they shouldn't, who doesn't trust when they should, and who is constantly trying to merge with another to find a "home." What are a bpd patient's biggest problems? Trust and boundary issues.

Need more data that bpd is a developmental problem? The DSM IV-TR states that a diagnosis of bpd should NEVER be applied to adolescents. Why? Because, to some extent, much of "normal" adolescent behavior can fall somewhere on the borderline spectrum. They all tend to have moments when they are self-centered, lacking in empathy, hyper- or hypo-sensitive, obsessive, irritable, etc. To label them before they have actually reached adulthood is to confuse age-appropriate inappropriateness with pathology.

That is not to say that a few of these kids aren't well on their way to an adult diagnosis of bpd, only to stress that they all have the capacity to appear somewhat dysfunctional at this stage of their lives.

Adolescence is sometimes referred to as the second toddlerhood. It may be that more severe bpd patients arrested at a preschool level, while those with milder symptoms got hung up farther along.

I don't want to be guilty of over-simplification, so I will add that the arrested development is a SYMPTOM and not a cause of bpd. What stopped these folks in their developmental tracks could be anything from abuse (in any manner and degree imaginble), organic causes, toxic exposures, misinterpretations and apprehensions about life circumstances, well-meaning but disastrous child-rearing practices, innate sensitivity to various stimuli, catastrophic emotional loss, and the list goes on.

You start with the causitive agent(s). Stir in arrested development and the undesired responses it generates. Add the ongoing litany of negative consequences that bpd patients carry in their voluminous baggage (relationship disasters, financial wreckage, employment nightmares, legal entanglements, substance abuse, self-harm, violence, needy/messed-up kids of their own, and more). And top it all off with the ineffectual, irritating, frightening, dangerous, and sometimes truly bizarre coping strategies of someone who trusts nothing and no one and who has become a law unto themselves. Then you will begin to see how terrifying a place the world is to bpd patients and how ill-equipped they are to do anything different without compassionate intervention.

I am in agreement with you, hsieh, that bpd patients need far more from the mental health system than to be labeled, marginalized, and mocked. I also agree that much of what we are doing for them now is ineffectual. We merely stabilize them and send them back out the door with their chaotic pathology largely intact.

I do not agree that changing the name of their diagnosis will improve their care. They're still going to be the same crazy-making folks they have always been.

I do not agree that our trying to understand the complexity of their needs has CAUSED the needs. If our current treatment has exacerbated the problem, it has done so only because it does not allow or encourage the kind of limit-setting and concommittent nurturing these patients need to move forward.

As for sending bpd patients to Africa, consider this. It may be that one does not see many bpd patients in third world countries because they don't stand out in places where extreme poverty, violence, and pervasive disease and dysfunction have eroded boundaries to the point where entire populations might be seen as borderline in nature. It could be that those who continually annoy and enrage others eventually get themselves killed. It could be that, in areas singularly lacking in hope, their own disordered thinking further overwhelms them and they kill themselves.

Sending first world pbd patients to a third world country in the hopes that culture shock and the lack of indulgence will cure them is like sending someone with psoriasis to a primitive leper colony. Camouflage, maybe, but cure, no.

You have repeatedly brought up a desire for the use of alternative treatments, but other than your impractical and inhumane geographical one, you have not given us any suggestions of your own. Are you as puzzled by, and lacking in tools to deal with, this diagnosis as your co-workers? If so, are you willing to look beyond transporting pbd patients to another hemisphere and brainstorm some rational, practical methods of dealing with this frustrating and lonely group here and now?

What can we as clinicians do to get them stop hurting themselves and others? How can we help them learn to trust appropriately and to develop healthy boundaries? These, in the end, are the questions that matter most.

[Marie_LPN, RN, LPN, RN]

I do not agree that changing the name of their diagnosis will improve their care.

Especially where the mentality of the caregiver is concerned.

[WhatNext?]

rn/writer

Thank you for post #61. :bowingpur Awesome, sensitive and professional...

Wish I could have said what you said as well as you did.

Patients with borderline personality disorder suffer terribly. Their families and friends suffer as well. We do them a huge disservice when we disrespect them by calling them names and collude with a work culture that does not look beyond their behaviors.

[Multicollinearity, BSN, RN]

Since my mother is a borderline, I do understand from personal experience how and why physicians and nurses can snap and vent behind closed doors. It is only expected and human, because borderlines are masters of pushing buttons. I cannot describe the shallow, me-me-me, I love you, I hate you, toddler attention seeking behavior and do it justice. I think it is important to remember the need to vent behind closed doors. I'll leave talk of better treatment of the disorder to others with more experience.

[Multicollinearity, BSN, RN]

People don't "make" borderline personality disorder "detailed and in depth." It IS a complex disorder, in part, because is has become a catch-all phrase that covers many variations and degrees of dysfunction.

To come up with a one-size-fits-all treatment plan is foolhardy and dangerous. And it points to the very same impatience that you refer to with such distaste in your co-workers. They deal with their frustration by referring to the patients with disrespect and calling them drama kings and queens. You deal with yours by bringing up an impractical solution like shipping them to a third world country, an idea that shows insensitivity to both the patients AND the country you're proposing they be sent to.

I was sympathetic to your posts initially. I thought that you were saying that the present system is far too enabling of disordered behavior and has proven largely ineffective. I can't argue with either of those thoughts. I also agree that it's wrong (though I do believe understandable) for staff members to negatively label their patients and dismiss their complaints as nothing more than manipulation and dramatics.

It seemed that you were holding out for bpd patients to be viewed with more respect and given more effective treatment. Both are admirable goals.

Now, I'm beginning to question your basic understanding of borderline personality disorder. And the amount of respect YOU have for those so afflicted.

You speak of renaming bpd "child abuse disorder" so that it can be taken more seriously and staff members will not be tempted to dismiss the patients' acting out and other symptoms as just so much drama. While child abuse is often a component of a bpd patient's history, it is hardly universal. There are many patients who grew up in fairly stable homes who were not beaten, molested, or tormented, who still somehow end up as dysfunctional as the next bpd patient. And, as you pointed out, there are those like your friend, who come through a wicked past without becoming warped by it.

I say all of that to say that renaming bpd "child abuse disorder" so that the patients will invite a more sympathetic response is inaccurate, misleading, and simplistic. What we need is a better overall understanding of bpd itself and what the world looks like to these patients along with treatment options that actually accomplish something. Increased empathy and effective treatment strategies will do much to render staff more capable and caring.

Although some might disagree, bpd IS (at least functionally) a developmental disorder. If you doubt that, take a look at any normal two- or three-year-old child and compare them to an adult borderline patient. What you will see are boundary issues, self-centered thinking, distrust, mistrust, a long list of fears, an exaggerated quest for autonomy, diminished or absent empathy, appetite-driven actions, obsessive attachments, great impatience, hypersensitivy/insensitity confusion, and a host of other intense needs and desires.

What is normal (and sometimes even cute) in a toddler is problematic and disturbing in an adult. And while toddlers are, by definition, limited in the amount of damage they can do, adults are often free to wreak havoc on themselves and everyone around them. Because they are dependent and pretty well confined, toddlers are much more amenable to "treatment" than your average adult bpd patient. That is to say, a combination of nurturing, consistent limit-setting, and short-term posititve and negative consequences can help a toddler to safely move forward into the next level of maturity. Being dependent, they don't have many options to resist.

Somehow, for whatever reason, these bpd folks got left behind. And now, because they are chronological adults, they have rights and access to all kinds of "goodies." They are emotional toddlers with car keys and checkbooks. They can legally enter into binding contracts (including marriage) without anything close to a real understanding of the significance of their actions. One motto for the severely bpd might be, "It seemed like a good idea at the time." Another might be, "It wasn't my fault," followed by a catalog of excuses and extenuating circumstances.

If you look at Erickson's developmental stages, you will see that the first two--trust and autonomy (the ability to recognize one's self as an individual) cover the first three years of a child's life. If these stages are messed up, you will end up with a child who trusts when they shouldn't, who doesn't trust when they should, and who is constantly trying to merge with another to find a "home." What are a bpd patient's biggest problems? Trust and boundary issues.

Need more data that bpd is a developmental problem? The DSM IV-TR states that a diagnosis of bpd should NEVER be applied to adolescents. Why? Because, to some extent, much of "normal" adolescent behavior can fall somewhere on the borderline spectrum. They all tend to have moments when they are self-centered, lacking in empathy, hyper- or hypo-sensitive, obsessive, irritable, etc. To label them before they have actually reached adulthood is to confuse age-appropriate inappropriateness with pathology.

That is not to say that a few of these kids aren't well on their way to an adult diagnosis of bpd, only to stress that they all have the capacity to appear somewhat dysfunctional at this stage of their lives.

Adolescence is sometimes referred to as the second toddlerhood. It may be that more severe bpd patients arrested at a preschool level, while those with milder symptoms got hung up farther along.

I don't want to be guilty of over-simplification, so I will add that the arrested development is a SYMPTOM and not a cause of bpd. What stopped these folks in their developmental tracks could be anything from abuse (in any manner and degree imaginble), organic causes, toxic exposures, misinterpretations and apprehensions about life circumstances, well-meaning but disastrous child-rearing practices, innate sensitivity to various stimuli, catastrophic emotional loss, and the list goes on.

You start with the causitive agent(s). Stir in arrested development and the undesired responses it generates. Add the ongoing litany of negative consequences that bpd patients carry in their voluminous baggage (relationship disasters, financial wreckage, employment nightmares, legal entanglements, substance abuse, self-harm, violence, needy/messed-up kids of their own, and more). And top it all off with the ineffectual, irritating, frightening, dangerous, and sometimes truly bizarre coping strategies of someone who trusts nothing and no one and who has become a law unto themselves. Then you will begin to see how terrifying a place the world is to bpd patients and how ill-equipped they are to do anything different without compassionate intervention.

I am in agreement with you, hsieh, that bpd patients need far more from the mental health system than to be labeled, marginalized, and mocked. I also agree that much of what we are doing for them now is ineffectual. We merely stabilize them and send them back out the door with their chaotic pathology largely intact.

I do not agree that changing the name of their diagnosis will improve their care. They're still going to be the same crazy-making folks they have always been.

I do not agree that our trying to understand the complexity of their needs has CAUSED the needs. If our current treatment has exacerbated the problem, it has done so only because it does not allow or encourage the kind of limit-setting and concommittent nurturing these patients need to move forward.

As for sending bpd patients to Africa, consider this. It may be that one does not see many bpd patients in third world countries because they don't stand out in places where extreme poverty, violence, and pervasive disease and dysfunction have eroded boundaries to the point where entire populations might be seen as borderline in nature. It could be that those who continually annoy and enrage others eventually get themselves killed. It could be that, in areas singularly lacking in hope, their own disordered thinking further overwhelms them and they kill themselves.

Sending first world pbd patients to a third world country in the hopes that culture shock and the lack of indulgence will cure them is like sending someone with psoriasis to a primitive leper colony. Camouflage, maybe, but cure, no.

You have repeatedly brought up a desire for the use of alternative treatments, but other than your impractical and inhumane geographical one, you have not given us any suggestions of your own. Are you as puzzled by, and lacking in tools to deal with, this diagnosis as your co-workers? If so, are you willing to look beyond transporting pbd patients to another hemisphere and brainstorm some rational, practical methods of dealing with this frustrating and lonely group here and now?

What can we as clinicians do to get them stop hurting themselves and others? How can we help them learn to trust appropriately and to develop healthy boundaries? These, in the end, are the questions that matter most.

Thank you. I look forward to reading your thoughtful posts.

[Thunderwolf, MSN, RN]

Thank you, Miranda. You echo my thoughts completely, especially regarding how BPD is a developmental disorder. "The BPD as a toddler with car keys and a checkbook" images this quite well. Also, I agree that not all BPD's are from broken back grounds or have been abused....although many are. I am so proud to have you as one of my Moderators on this forum. Thank you again for that wonderful post.

[hsieh]

i guess i have nothing else to add. does anybody else have alternate treatments?

[DidiRN]

Okay, I have zero psych experience (other than nursing school many years ago) but have also been raised by a mother with BPD.

Maybe this is something that has already been tried, or maybe you guys with the psych experience don't think this would work, but what about an intensive inpatient or outpatient treatment center that specifically treats BPD? Or is there already something like this? Or are most of them so non-compliant they wouldn't stay in a program like this?

I remember years ago, psych patients would sometimes stay in the hospital for several months, if not years. It seems like nowadays they are very quick to throw alot of people out on the street again, do you think if someone with this disorder was to stay and be treated for quite some time, the possibility of recovery from this might be better?

Like I said, I have zero psych experience and am just talking from a point of view of a daughter of a BPD who has done alot of reading on it; you guys are the experts on this :)

i guess i have nothing else to add. does anybody else have alternate treatments?

[hsieh]

the goal of mental health is to keep people in the least restrictive enviroment possible. i would think locking up borderline would delay it's development even more. the best treatment is life itself not being locked up. another thing i just thought of is vidio tape people with their permission and have them watch it. then a professional can exam the video with the patient and explain how they are coping.

[LydiaNN]

the goal of mental health is to keep people in the least restrictive enviroment possible. i would think locking up borderline would delay it's development even more. the best treatment is life itself not being locked up. another thing i just thought of is vidio tape people with their permission and have them watch it. then a professional can exam the video with the patient and explain how they are coping.

Sorry... and how does the least restrictive environment theory apply to being sent off to Africa, removed from everything they've ever known?

[DidiRN]

I didn't say anything about "locking them up"...in fact, I mentioned that they might be too non-compliant to go through with it, which means that I was not suggesting they were being forced into it. They could leave at any time.

Was just wondering if a controlled environment with staff particularly geared to treating this type of patient for a lengthy period of time might be helpful or not.

the goal of mental health is to keep people in the least restrictive enviroment possible. i would think locking up borderline would delay it's development even more. the best treatment is life itself not being locked up. another thing i just thought of is vidio tape people with their permission and have them watch it. then a professional can exam the video with the patient and explain how they are coping.

[EricJRN, MSN, RN]

Was just wondering if a controlled environment with staff particularly geared to treating this type of patient for a lengthy period of time might be helpful or not.

I like the thought of that. Specialty units exist for other mental health problems (such as eating disorders) and medical issues, so why not?

The only problem I see with videotaping/critiquing: Since people with borderline personality disorder can be particularly sensitive to criticism, would that be likely to place distance/friction between therapist and client? I know that limits have to be set, but I think reviewing videotapes might be carrying it a little too far.