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.

[cardiacRN2006, ADN, RN]

Hey hsieh, I have an alternate form of treatment for you and your co-workers to try. It's called compassion. Give it a whirl.

[LydiaNN]

Hey hsieh, I have an alternate form of treatment for you and your co-workers to try. It's called compassion. Give it a whirl.

Oh but don't you know, cardiacRN, if you show ''these'' people compassion, they'll never be ''cured''!

[rn/writer, RN]

i understand that millions are spent on it unsuccessfully. where i work the things that have been said in this thread are not taught. we are taught they are self centered, ect. one of my co workers was talking how a bpd was wanting attention for cutting on herself. the patient reported this and my boss told my co worker - you NEVER tell a bpd they're trying to get attention because they will do anything to prove you wrong. this statement tells me that bpd are nothing more than people who live to play games. you can't cure people like that. just like you can't cure people who like heavy metal music. wasting millions of dollars trying to cure them is ridiculous. my ideas are aimed at the point of the prob - go to an enviroment where you can't play games and maybe you'll learn you can live without playing games. this isn't an illness - it's a lifestyle. a lifestyle of playing games. and as for talking about the money - people were saying it's inhumane or not empathetic - if donald trump has gold furniture does that mean he's inhumane or not empahtetic becasue there are people starving to death and he buys gold furniture instead of feeding them? don't call people inhumane or empathetic when people starve to death and others drive suvs and live in large air conditioned houses.

Your co-workers may label the patients and get caught up in their power struggles and drama. (Remember, you started this thread by chastizing them for judging the patients and acting as if it were their own fault for being borderline.) Yet you have judged the bpd population far more harshly. And your solutions are nothing short of punitive and cruel.

To equate bpd with an attraction to heavy metal music is beyond belief and shows a truly inadequte grasp of the condition.

Yes, bpd patients need to have their ability to "play games" curtailed. But they need the limits set in a caring and supportive way, much as you would do with a small child. Enabling hurts them as much as it hurts those around them. When the healthy people in their lives can get past their own emotions, set healthy non-punitive boundaries, and help the patients work through the messes they've made and learn better ways to live, wonderful things can happen.

One of the biggest obstacles to all of this is that the borderline population is continually subjected to the rejection and rage that their crazy-making behavior generates. This precludes the building of trust and motivation that bpd patients need if they are ever to WANT something more out of life. They're an easy bunch to hate. And they're already so lonely that this can push them to the brink of despair. Sometimes they act out, then, and make a play for attention. It's a crippled way of saying, "I NEED something and I don't know any other way to get it." Pitiful, but desperate.

Health care practitioners are as vulnerable as the rest to developing a snarky and judgmental attitude toward bpd patients, and it would appear that, despite your low opinion of your co-workers, you have given in to the negativity every bit as much as they have. The only difference is that you tried to have us believe you had compassion for those with bpd when the reality is just the opposite.

When you initially asked for alternative treatments, I can now see that instead of looking for ideas that might help bpd patients get better, you were actually asking for ways to get rid of the borderline population.

If this is the best you have to offer the patients, if you truly believe that bpd people are nothing more than selfish, overindulged troublemakers and we need to "drop them" to teach them a lesson, please, find a different job where you can do less harm.

[LydiaNN]

Miranda, excellent post, as always.

hseih, I find the idea of you being a psych nurse utterly dismaying. I feel for the patients and the families if this is the standard of care tolerated at your facility. A nurse that doesn't understand the difference between a college student electing to ''spread the wings'' by going away to school being compared to a bpd patient with minimal coping skills under the best of conditions, being sent off to a developing nation to sink or swim (and they will all sink!) is certainly not qualified to work with this population. Why you believe that heavy metal and SUVs would enter into the equation can just stay a mystery. I am sure that even if you provide an explanation, it won't be any easier to follow than your other rationales. Yes, patients with borderline personalities do play games to get attention. Is this supposed to be new information to us? It is part and parcel of the disorder. When you tell us that answers should become apparent in 2 days or we're fools or suggest that motivating patients to change their behaviors is a simple matter of watching a videotape and ''explaining'' what they're about to see, you display a level of ignorance about this disorder that one typically sees only in the most unenlightened lay person. It doesn't appear to me that you are the least bit interested in discussing alternate treatments unless said treatments will require no hard work on your part.

[EricJRN, MSN, RN]

I'm impressed by the level of restraint shown by the moderators (Thunderwolf, rn/writer and maybe others) in keeping this thread going. Thanks guys, for trying to encourage some productive discussion.

[Multicollinearity, BSN, RN]

Yes, bpd patients need to have their ability to "play games" curtailed. But they need the limits set in a caring and supportive way, much as you would do with a small child. Enabling hurts them as much as it hurts those around them. When the healthy people in their lives can get past their own emotions, set healthy non-punitive boundaries, and help the patients work through the messes they've made and learn better ways to live, wonderful things can happen.

This is so true. I ended up seeing a psychologist because my mother (borderline) was driving me nuts. Once I understood what was going on with my mother I no longer got so angry and upset. When mom splits me now, I just say to myself in a non-minding way "you've been split. And so it goes. Moving on." Before I would react how any person would - not knowing what was going on.. hurt... puzzled. So anyway, I've been able to set boundaries with her and be gracious about it despite her rants, splitting, crazy-making chaos, and alternating adoration. It's taken time but she is definately getting better. That couldn't have occured if those around her didn't understand the *specific* pathology. Through knowledge of her disorder, firm boundaries and lots of love she has significantly improved in the past two years for the first time ever.

It's unrelated to the above topic, but I cannot recommend enough seeing a therapist for those dealing with a borderline loved one. Suddenly my low self-esteem made sense, among other things.

[hsieh]

i guess i have nothing else to add. i think it would be good to hear from a nurse who grew up in africa though. or any other culture where they don't have this.

[rn/writer, RN]

i guess i have nothing else to add. i think it would be good to hear from a nurse who grew up in africa though. or any other culture where they don't have this.

Sigh . . .

[rn/writer, RN]

This is so true. I ended up seeing a psychologist because my mother (borderline) was driving me nuts. Once I understood what was going on with my mother I no longer got so angry and upset. When mom splits me now, I just say to myself in a non-minding way "you've been split. And so it goes. Moving on." Before I would react how any person would - not knowing what was going on.. hurt... puzzled. So anyway, I've been able to set boundaries with her and be gracious about it despite her rants, splitting, crazy-making chaos, and alternating adoration. It's taken time but she is definately getting better. That couldn't have occured if those around her didn't understand the *specific* pathology. Through knowledge of her disorder, firm boundaries and lots of love she has significantly improved in the past two years for the first time ever.

It's unrelated to the above topic, but I cannot recommend enough seeing a therapist for those dealing with a borderline loved one. Suddenly my low self-esteem made sense, among other things.

Thank you so much for sharing this. Your comments aren't off topic at all. In fact, they are right ON target. I'm sorry you had to learn how to mother your mother, but I'm glad, for her sake as well as yours, that you COULD learn how to depersonalize her crazy-making and let go of much of the negativity. You will both be healed and blessed by that decision.

I, too, recommend therapy/counseling for those involved with bpd patients. It helps to have a place to vent. And talking with someone who understands the borderline mindset can shed so much light on why they do the things they do. And how you can take evasive action without taking offense.

The truth is that pbd patients are among the loneliest people in the world. They need others to set aside the very rejection and anger they provoke and find ways to love them in spite of what they do. This, and only this, kind of reaching out and connecting will build the trust that will allow them to mature.

I admire you so much for learning to accept your mother as she is, even as you set the much-needed boundaries. It takes a heck of a lot of committment on your part to make such an effort, and I'm sure it's a work in progress.

Your post has been the highlight of this thread.

Thank you and thank you again.

[hsieh]

i've learned a lot. i learned it's a developmental disorder, some people take it seriously and think it's real (unlike in my part of the country), it's how a person deals with the world according to their own unfortunate upbringing, and that there are people who actually care about this population (unlike in my part of the country). it's so complicated and ingrained it's very difficult to treat successfully. the mental health system does the best it can. there was a lot of good info in this thread.

[rn/writer, RN]

i've learned a lot. i learned it's a developmental disorder, some people take it seriously and think it's real (unlike in my part of the country), it's how a person deals with the world according to their own unfortunate upbringing, and that there are people who actually care about this population (unlike in my part of the country). it's so complicated and ingrained it's very difficult to treat successfully. the mental health system does the best it can. there was a lot of good info in this thread.

Yes! You are right that the mental health system is very limited in its understanding and efforts to care for bpd patients. Borderline folks are their own worst enemies and we, as practitioners, have historically not been very aware or kind in how we treat them.

If you now have a different understanding of this sad and lonely population, maybe you will have an opportunity to do something different and set an example for you co-workers. Just as the bpd patients don't "intend" to be so messed up, most health care workers don't "intend" to be mean-spirited and unhelpful. They just don't know any other options.

If you could show them how to get past the crazy making and set kind but firm limits, you might help both patients and staff alike.

That is a tall order in any part of the system, but one person CAN influence others.

Think of a roomful of preschoolers wearing adult bodies and having adult opportunities that they simply cannot manage. And think of how awful they feel when they keep getting people mad at them when they're only trying to do what makes sense to a little kid. They need the safety of limits and the comfort of acceptance (of them as people, not their behavior).

Armed with this knowledge, you really might be able to make a difference where you work.

Please, let us know if anything you learned here changes your approach and if you meet with success.

I really do wish you the best.

[VickyRN, MSN, DNP, 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.

Truly outstanding post, Miranda. Thank you for shedding some light on an area with which I have little expertise (psych) :) Whatever our professional specialty may be, we are certain to encounter people suffering from BPD, and this thread has afforded me much insight.