Hey, wait, where are you all going? Come back!
Utter those three fatal words in mental health services, and all the pejoratives come out. Let’s have a roll-call, shall, we? Let’s see, we’ve got “manipulative”, “demanding”, “drain on resources”, “not really a mental illness”…oh yes, and let’s not forget “untreatable”.
Now, let me introduce you to Beth.
Beth is 15. She’s been coming to our CAMHS clinic for a year, and over that year has been seeing a nurse therapist (Yeah! Quacktitioner! Quacky quacky quack quack…) once a week. She’d been referred by the GP due to angry outbursts, mood problems, self-cutting and having unprotected sex with older boys. During her sessions of therapy it emerged that she’d had a pretty horrendous few years, with periods of physical abuse by her mother, the acrimonious break-up of her parents and a long period of physical illness during childhood.
Over the past year she seems to have gone from crisis to crisis, not helped by the constant demanding behaviour she displays towards both parents, deliberately goading them into punishing her, and then becoming extremely distressed when they then impose that very same punishment. She’s been shuttling between the homes of the two estranged parents, depending on which of them she’s had a massive bust-up with most recently.
Once a week, she comes to therapy, never misses a session, talks non-stop to the nurse therapist and then goes away and strikes up yet another screaming row with whichever parent she’s staying with that week.
Yes, ladies and gentlemen of the readership, what we have here is a child with an attachment disorder growing up into a teenager with a borderline personality disorder.
The nurse therapist feels completely ground down by Beth. “I’m seeing her once a week, every week, and each time it’s the same,” she sighs. “We go through the latest crisis, talk about what she could have done differently, and then she goes away and before too long there’s another crisis. I feel like I’ve spent a year with this girl and got absolutely nowhere.”
We decide to reflect on the case as a multi-disciplinary team. As we do so, we start to notice a few things that don’t tally with the nurse therapist’s perception that there’s been no therapeutic gain. For one thing, Beth has stopped cutting herself. Okay, she’s still having these massive screaming rows with her parents, but whereas they used to take place once every 2 or 3 days, it’s now once every 2 or 3 weeks. And once in a while, just every so often, there’s been a few times recently where rather than having a screaming row with her mother, Beth has sat down and talked with her.
One of the staff in the MDT suggests that the nurse therapist has a chat with Beth about what she feels she gains from the sessions. After all, she always comes to them without fail, so she must feel she’s gaining something from it. The nurse therapist puts the question to Beth, and her answer is pretty straightforward, “Because you listen to me.”
What Beth gets from it is one hour, once a week with an older female figure who doesn’t reject her in the way that her mother did, and accepts her and listens to her in a way that her mother didn’t.
I can’t prove that this helped to improve her behaviour. I don’t have any statistics or research papers for that. But on an intuitive and anecdotal level, I strongly suspect that it did.
What Beth needed was someone to walk alongside her, and be there for her over a sustained period of time. Doing that can be labour-intensive, and incredibly demanding for the person doing it - hence the nurse therapist having become so completely ground down that she was unable to see the real improvements that Beth was making. Hence it’s not just Beth who needs to be supported, but the person who’s supporting Beth also needs support of their own.
Now, how does the above fit into all the impressive policy talk about evidence-based, time-limited use of whichever therapeutic models are flavour of the month? We can talk endlessly about models like cognitive-behaviour therapy, solution-focused therapy, dialectical behaviour therapy…where’s the recognition of the actual relationship between clinician and patient, and the potential healing power of that relationship?
And when we say that personality disorders are “untreatable”, could that be simply a way of saying that some people have issues that require something more than a prescription for some fluoxetine and six to eight sessions of CBT?
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44 Comments
Interesting post Z. Especially your final paragraph.Often wondered who came up with the idea that 6 to 8 CBT sessions can sort out a problem.Everybody’s different so how does that figure ?
Is sad that the only adult female listening to Beth is a therapist.But I guess she’s not the only teenager in this situation.I see a great many potential Beths around the town I’m living in.
Great post. I have recovered from BPD, although it has taken 8 years of therapy, 3 hospitalisations and a ton of medication to get there.
I have now been discharged from psychiatric treatment and no longer rely on medication. I still have ‘issues’ but doesn’t everyone?
My recovery is due to a number of things, but most of all it is due to mental health professionals who did everything they could (and more) to help me. I had to relearn how to trust other human beings, and because they cared and supported me, sometimes out of hours, I began to realise that the world wasn’t necessarily an evil, dangerous place.
Patients with BPD can recover, but it takes time, a lot of patience, and a sense of humour. I have been very, very lucky, and I owe my life to my treatment team, although they are modest about this. It makes me sad that not everyone will be so fortunate, but this post makes me feel slightly more optimistic.
Thank you.
Lou
Have just found this blog through “The Rollercoaster of Life”.
I’m interested in this BPD post because Mrs Carr is having terrible issues re mental health issues and we wonder if she has been tagged as BPD. I have asked and been assured that there is no hint / assumption etc of BPD in notes but no clinician will explain what is their diagnosis.
Rather than go into details here you can read about Mrs Carr’s problems at http://calumcarr.blogspot.com where I have just started a web campaign to force the NHS trust into action.
It’s great that Beth has a place to come once a week and be listened to (wouldn’t we all like that?) and it’s great that your team has the luxury of a nurse therapist who’s available to do that. It’s also brilliant that said therapist has sufficient support to continue with what must be terribly exhausting work.
If only the same applied to the many CMHTs, A&E departments and acute psychiatric wards where others with BPD present themselves for help. BPD patients don’t play the game. They don’t get better very quickly, they aren’t suitably amenable to what little we can offer them and as a result, the inadequate system in which they find themselves labels them as “untreatable” and further rejects and marginalises them.
The answer, of course, is more resources. But with so many compelling demands on resources, how do you prioritise who gets what? Evidence-based healthcare may have its problems, but it’s the best we’ve got at the moment to make those sorts of decisions.
Yes!
I only recently found out that part of my diagnosis was avoidant personality disorder. Treatment for that was not mentioned - but the 18 sessions of psychology treatment which were (eventually) offered were, thanks to an excellent practitioner, extended into about 40. Ending the sessions has been traumatic because of other factors, but I know the treatment helped, and a big part of that hep, as you state, was having someone who was consistently there, week after week; someone who listened to me and to how I was feeling; someone who did not condemn me; - all things I lacked as I was growing up. 40 sessions - yes, that is a lot. But if those 40 sessions mean I can avoid extended sick leave and hold down a professional role; if they mean I can avoid passing on my own problems to my kids (something my Mum was unable to do); if they mean I will need less support from my GP, less expensive medication in future, then that has to be cost effective. And apart from that, the treatment has effected a much happier life for me - surely that has to be worthwhile too?
Will come back to this posting because one of my nearest and dearest as BDP as their label and all it has served to do is exclude them from just about everything.
What I find most alarming is, when I read mental health support forums on-line, how many women in the US and Canada appear to be diagnosed as Borderlines. In contract, I think in all my time in the mental health system in the UK (10 years+ as a patient with multiple hospitalisations, going to support groups etc) I have met 2 ladies with this diagnosis in total.
Some years ago, I asked my (NHS) psychiatrist about this as I was curious. He said that although the condition does exist, there is a tendency among incompetent doctors to overdiagose this condition as a way of “getting back” at patients who fail to recover from their depressive illness, especially in North America, and that said overdiagnosis does the patients no good whatsoever.
Also that unqualified persons (therapists etc) sometimes assume that self harm = borderline, whereas lots and lots of depressed people self-harm, and it’s not especially indicative of Borderline unless comorbid depression and anxiety have been ruled out.
An untreated depression is not a personality disorder, he said. He’s pretty well-thought-of by his colleagues so I can’t imagine he’s alone in the above opinion. I can’t give any more details as I doubt he would express himself publicly in that manner! (I have since moved to another borough).
Hi there, I’m new to this site.
This thread grabbed my attention, as someone who’s been generously given the BPD label myself, as a friend of someone badly mistreated as a result of a BPD label for years before her diagnosis was changed (doh!), and now as a student nurse entering placements where unenlightened staff members bitch about “bloody P.D.’s” constantly behind the staff room glass and where there is a deeply imbedded culture of institutionalised prejudice against anyone with this diagnosis.
On my acute ward placement, people who were considered “ill” were generally those who wanted nothing to do with the services, and they ended up wrapped up and smothered in the cotton wool of paternalism, whereas those who voluntarily came forward for help were generally turned away - they were the “behavioural” “malingerers” who were “just after more meds” or “pathetic” “attention-seeking”. And, yes, they were “untreatable” as well.
I found it so hard to listen to this kind of talk from nurses, support workers and psychiatrists, and would sometimes challenge staff with a few gentle reminders about the sorts of things that may have happened to people in their pasts to make them need the kinds of coping strategies that they used today. Ok, so they weren’t really gentle reminders and I was much more likely actually to go off on rants in the middle of ward round, shocking all present at my audacity, but, really, these things needed to be said.
“Personality disorder” is a waste-bin diagnosis. All it’s good for is for making it easier to avoid really Being With the person in their struggles and their pain (because they’re P.D. so we don’t have to identify with them). I’ve met a few people who’ve found it a useful label but not many at all compared to the number of people who’ve found it soul and hope destroying. I had my psychiatrist reassess me recently and he now classifies me as “emotionally unstable personality disorder - resolved”. It’s just so hard, having had that label, not to put everything I do and go through down to being “P.D.” - every time I get upset or angry about something, I feel like it’s going to be put down to “borderline rage”, even when the anger is perfectly appropriate. I’m now working really hard to leave that really unhelpful identity behind and just to accept how I am as being just how I am, not “disordered”, just me.
I would like to see this diagnosis abolished (along with the whole of the rest of DSM and ICD actually, but let’s start here..) and people instead to be given the opportunity and support to describe their own experiences in their own way and to come to their own understanding about what it all means. But maybe that’s just my borderline personality trying to make things difficult….
You could argue that anyone with mental illness has a personality disorder.
You could argue that many people without a labelled mental illness have personality disorder.
What actually constitutes personality disorder?
Is it one of those checklists with 3 compulsory elements and a variety of optional extras?
I am not poo pooing it as a label per say. Although I find most labels more barriers to anything positive than positves.
But if we are going to have labels, which the system encourages, then we need appropriate services to respond.
Meanwhile back in la la land
It’s good to hear from Lou and Disillusioned that something being done by mental health workers is doing some good for people with BPD. (I won’t say mental health professional in case Dr’s C and Rant are listening).
We had a patient with BPD when I was working in community. She was passed from CPN to CPN and from Consultant to Consultant as she literally wore each worker out. She had every talking and drug therapy going and when at her worst could quite literally paralyse the entire system with her dozens upon dozens of telephone calls and allegations of abuse against whatever member of staff had earned her displeasure. She was banned from A&E and finally from the CMHT and only when she stopped receiving a service did things start improving. I saw her in A&E the other day and the transformation was quite literally astounding. Off all medication she had lost weight, she was working, and I was able to have the first reasonable conversation I have ever had with her. I had to agree that mental health services had not done her any favours; in her case less was definitely more.
DeeDee Ramona is right BPD is very often a dustbin category used to exclude patients from receiving a service although in the above case that may not have been such a bad thing.
I think that the diagnosis of BPD is not always diagnosed because the recommended treatments are not everywhere available in the NHS. There has been a lot of research in psychotherapeutic treatments see http://ajp.psychiatryonline.or...../165/5/556. Psychotherapy works for a lot of people with BPD. It is not 6-8 sessions with CBT, but 3-5 years of therapy with the same therapist. Fonay (UK, Mentalisation Based Therapy) has proven his therapy gives value for money. It is time to change the attitude towards BPD in the UK.
Wow Z, at long last you`ve stopped worshipping at the altar of the evidence base and started listening to your intuition. Long may it continue.
Beakie, rather remarkably I`ve agreed with much that you`ve said of late ( quite disconcerting for me ). However, the deafening, incessant bleating for “more resources” is as boring as it is mindless. Why, exactly, do the positive, listening role models in this young girls life have to be nurse therapists ?. I opined that the last young patient Z wrote about might well benefit from junior rugby. There are all sorts of organisations who can make valuable contributions. Now that anecdote is back in fashion I can tell you about the consultant anaesthetist in these parts who was required to do a first aid course before becoming a co-ordinator for the Duke of Edinburgh`s Award Scheme ( perhaps Prince Edward is doing something vaguely useful after all ). I`ve recently applied to help out with a youth organisation, I`d be hugely surprised if the application forms for MI5 are any longer. Liberating voluntary organisations from the mire of red tape is only one avenue. There are any number that can be explored before whining for “more resources” becomes a necessity.
OSB: I`d be hugely surprised if the application forms for MI5 are any longer.
Surely, OSB, MI5 can have a nice, short form, as they already know everything they need to know about any applicant already :-).
Thank you for that powerful perspective. I’ll be getting a couple of friends to read this because even just anecdotally it’s really great to hear from a professional that sitting with someone with BPD, and engaging with them works.
It has, equally anecdotally, been the only thing that has helped me with good friends who have this disorder and who constantly struggle with a health system that reinforces their feelings of rejection for simply being the complex creatures they are. When I hear people bagging out BPD folks, my stock response is now that we find BPD so confronting because we all have borderline aspects to our selves if we look closely, and the only real difference is severity.
Ah but then there are all the equal ops and ethnic monitoring forms they will have to send you.
Q1. Do you have a beard?
Q2. Do you smell of foreign food? (Especially curry)
Q3. Have you recently holidayed in any of the following destinations?
i) Afghanistan
ii) Iraq
iii) Anywhere hot and sunny
Q4 Are you or any member of your family related to or acquainted with Osama Bin Laden or any of his known associates.
Q5. Which team do you support at Cricket?
i) England
ii) The winning side
Q6) Do you have any disability that might preclude you from being an MI5 officer such as
i) a hook
ii) blindness
iii) exploding trainers
Q7) Are you well tanned?
Regarding “Liberating voluntary organisations from the mire of red tape”. I was invited by MIND to become one of the people who contributes to their organisation, as I have some experinece of what they call “mental distress”. The form was thicker than a CPA package, I was warned that it would take 60 minutes to complete, and that filling it in may cause me some further mental distress.
Like any burocracy, they create their own mire of red tape.
Why, exactly, do the positive, listening role models in this young girls life have to be nurse therapists ?
They don’t, but they are in her case. I wasn’t talking about her specifically, but about people with BPD in general, who sometimes tend to suck up huge amounts of time, energy and resources to no real end other than containing them. Youth organisations may well be A OK for a 15 year old, but what about the 40 year old woman who’s a revolving door patient whose arms are a network of old and new scars and who lives on a diet of vodka, antidepressants and whatever other prescription medication she can get her hands on?
My Guru used to say to me: we are like toilets. Yes, once a week toilets. Just remember to flush it.
Yes, the The Cockroach Catcher is back from vacation.
Further. We forget that some aspects of mental functioning or dys-functioning” were not meant to be cured or got rid of jut like bodily functions like defaecation.
Again, remember to clean the toilet.
The Cockroach Catcher
Only listening might not be enough. I expect what the listening nurse is also doing for/with the patient is changing some core beliefs about the world and herself. This is what seems to be the working part of scheme focused therapy and mentalization-based treatment. I have met non-mental-health trained people who tried to listen to people with BPD, but didn’t have the patience to do it for years and in the end couldn’t cope anymore. And didn’t understand the dynamics of the behaviour. So they abandonded the person after some time. This didn’thelp the person in the end.
Beakie> as an aside: self-harm does not mean borderline. Lots of psychiatric patients, myself included, have problems with self-harm when ill. Same for the vodka mind you (not me in this case, I prefer the orange juice).
That’s a fair point, Dee Dee.
Thank you.
I’m with OSB. There’s an awful lot of medicalising and scientificalising of what is essentially caused by a fucked up version of youth and growing up.
People need people not just to listen or to offer advice and support but simply to validate their purpose of existence in the world. We do that by and thru the people around us. Having to have a ‘therapist’ is nothing more than an indictment against the disposable, dehumanising and divisionary bourgeois society we’ve become.
It’s got little to do with resources and more to do with attitudes. Staff just can’t be arsed in general and it’s no good having one good nurse every 3rd day when you’re in hospital and being abused across shifts for the other 2.
People with unfortunate and devastating life experiences need to regain confidence with the world. PD is a way, I believe, of stopping the world from hurting anymore and letting you down again - which is all we are reinforcing as true and necessaery when we incarcerate them, deem them ‘incurable’ and throw them away into a scrap heap of humanity.
I remember in early days of post grad nursing and learning what PDs in secure settings were capable of. I also learnt why.
++ Possible trigger below warning ++
It’s amazing how you can stop an aberrant nurse with derogatory comments from berating the annoying PD when you ask them -
“so nurse, how do you think you’d have coped with a shotgun in your mouth being forced to undress in front of your granddad when you were 8?”
I could seriously punch those nurses.
Does this make me PD too cos the nurse won’t have a clue why I should be so upset about her comments on “that PD patient”?
Apple said: “Only listening might not be enough. I expect what the listening nurse is also doing for/with the patient is changing some core beliefs about the world and herself. This is what seems to be the working part of scheme focused therapy and mentalization-based treatment. I have met non-mental-health trained people who tried to listen to people with BPD, but didn’t have the patience to do it for years and in the end couldn’t cope anymore. And didn’t understand the dynamics of the behaviour. So they abandonded the person after some time. This didn’t help the person in the end.”
I couldn’t agree with you more. Tallking is fine, but if it isn’t followed through with positive action, it can actually end up enabling the person suffering from BPD. It was only when my treatment team refused to ‘jump’ every time I threatened suicide that I learnt that difficult feelings pass and it wasn’t necessary to hand in my notice/leave the country/call the crisis team after a bad day at work.
I would also emphasise that it takes a highly trained professional to deal with BPD. It could be catastrophic in the wrong hands.
Beakie - just to explain why I pointed that out about self-harm. A lot of young female patients suffering from depression also have a self-harm problem. In some cases, there is a tendency to immediately assume they have BPD because of the self-harming behaviour.
This does them no good at all as what they need of course is treatment for the illness they do have, which is depression. Get rid of the depression, and you’ll get rid of the self-harm in most cases.
Men don’t seem to get tarred with the BPD brush quite so readily.
Can we please stop talking about “BPD” as if it existed as an entity? I really feel strongly (can you tell I wonder?…) that by using the language of “personality disorder”, we are feeding into this great mistaken idea that there are people who should be diagnosed in this way. There aren’t.
Is there a thing that one can call “Borderline Personality Disorder”? I’d say there is, in terms of describing a pattern of thinking and behaving caused by impaired attachments, usually as a result of childhood trauma or abuse.
But I’d agree that it can also be misused as a catch-all dustbin diagnosis. As DeeDee rightly points out, “self-harm” does not equal “borderline personality disorder”.
Oh, and just to respond to Apple’s point:
Only listening might not be enough. I expect what the listening nurse is also doing for/with the patient is changing some core beliefs about the world and herself. This is what seems to be the working part of scheme focused therapy and mentalization-based treatment.
Yes, the nurse in question was indeed steadily working to challenge Beth’s beliefs and help her to problem-solve so as to help change those beliefs. Slow work, and it needed to be done again and again to try to chip away at Beth’s core beliefs. This is why I don’t hold much with Rogerian models of counselling - I think therapists do need to sometimes challenge their clients and not just listen or reflect.
Z said:
“Is there a thing that one can call “Borderline Personality Disorder”? I’d say there is, in terms of describing a pattern of thinking and behaving caused by impaired attachments, usually as a result of childhood trauma or abuse.”
The trouble is, if you call it a “disorder”, it immediately traps that person in a negative framework - i.e., there is something wrong with you. Your personality is disordered. It’s not even like an illness that may have a cure, it’s just you - and P.D.’s don’t recover, so don’t expect to change.
This kind of labelling does more harm than good, I am convinced. We should be helping people to understand where their “maladaptive coping strategies” have arisen from and how they can gently replace them with more healthy alternatives. We should even be congratulating them on having used these coping strategies, because, hey, they’ve helped them to survive thus far…. Without self-harm, dissociation, and even ironically suicidal ideation, I would not be here today. I would have crumbled psychologically at the first hurdle, as a young child, or at one of the many thousands of hurdles since. My healing began when I started understanding why I do the things I do, and starting honouring the parts in me that are destructive, recognising their place in my story and even celebrating them, however strange that sounds. Noone wants to be hearing critical voices, but if you understand that they are trying to protect your system in some outdated way, then you can begin to have some compassion for them too. Then I could start to say, thanks guys, I have needed you to cope till now, you’ve done a brilliant job in fact (as evidenced by my still being here), and now it’s time for me to let you go, I have some new ways of being in place. That was everything to do with focusing on my strengths and nothing to do with “recognising I had a disorder”. I still occasionally struggle today, when I slip into that hideous psychiatric paradigm, with the hopelessness that being diagnosed BPD implies. It is a stigmatising, unhelpful, and harmful way of looking at things and, I repeat, I would like to see it’s use abolished entirely, as I don’t beleive it is necessary at all. The diagnosis of borderline personality disorder is simply an invalid concept, imposed onto survivors of some of life’s grittiest viccitudes by a profession obsessed with putting people and problems in boxes.
…. Also… I wonder how many people on the board have ever been in therapy? It’s not just people tarnished with the BPD brush that need help to change core beliefs about the world and themselves..as self-reflective practitioners, I believe that our core beliefs and values are something we should all be challenging frequently (yes, Peskystudent, that includes the belief just stated as well). The implication with BPD is that there are a group of people whose ideas about the world and themselves are very wrong. I would like to suggest that we all have some ideas that are not entirely helpful. We all have coping strategies that we have employed to get us to where we are today, and we could probably all do with revising some of those. …
… So, anyone who still believes that BPD exists, tell me, what is the difference between someone who “has a borderline personality disorder” and someone who doesn’t?
“So, anyone who still believes that BPD exists, tell me, what is the difference between someone who “has a borderline personality disorder” and someone who doesn’t?”
The extent to which they will destroy their world around and within themselves as a form of ‘coping’ - if it’s going to go to shit - may as well do it yourself and at least have some control over it.
“The extent to which they will destroy their world around and within themselves as a form of ‘coping’ - if it’s going to go to shit - may as well do it yourself and at least have some control over it.”
Mr Ian, do you mean by the second part of your answer that that is the way you believe “people with BPD” think?, I’m not very clear.
Since (I believe) we all have self- and other- destructive tendencies, or at least we all do things that we know aren’t really good for us, or don’t do things that are, aren’t we all on some kind of bordeline continuum? Who gets to decide at what point along that continuum someone is classified as having a “disorder”. And why would they want to do that?
Any other answers?
BPD exists, at the very least, in as much as you can find it in DSM and ICD-10 and people are walking around with that diagnosis. You can’t wish it away, any more than you can wish away schizophrenia or bipolar affective disorder. You can argue the toss about whether it is a valid or reliable concept, but for the moment it is there and it’s not going anywhere.
I also think it perhaps does some disservice to people who may be bewildered and traumatised by their own behaviour/thoughts/feelings and its sequelae to assume that nobody would want to make sense of that in terms of a disorder. It may work for you to dismiss it altogether, but some people might like a diagnosis to hang onto. For some people, it may be enormously helpful to think in terms of a disorder rather than conceptualise your behaviour/thoughts/feelings as the result of some inner failing or the failings of others.
““Personality disorder” is a waste-bin diagnosis.”
- Pesky Student
I’m having a blonde moment. What is the meaning, here?
We all agree that people who have such a label, diagnosis, explanatory framework, symptom cluster (or whatever you wish to call it) have valid experiences and experience distress.
If, through being distraught, you reckon it’s a disorder and merits help, then that’s the model of an illness with the possibility of treatment and benefit and improvement. Sure, you acn use different symptom cluster and resolution models but the concept’s the same. Things ain’t right, fix it, get better. This is one benefit of conceptualising it as a disorder.
If, through being distraught, you reckon it’s a normal and expected emotional state to be in, which most of use would be in if we’d the same past life experiences, so it’s nothing to do with illness and health care and psychiatry ’cause it’s all just the natural, normal state of affairs, is this better?
“You’re not ill, phew! You’re still here? No no, you can go home, now . . . ”
I could get on to nosological validity of diagnostic labels but I’ll not. Rather than categorising it as an entity or diagnosis or label, I’m much more interested in why this is seen as a bad thing?
Beakie said: “I also think it perhaps does some disservice to people who may be bewildered and traumatised by their own behaviour/thoughts/feelings and its sequelae to assume that nobody would want to make sense of that in terms of a disorder. It may work for you to dismiss it altogether, but some people might like a diagnosis to hang onto. For some people, it may be enormously helpful to think in terms of a disorder rather than conceptualise your behaviour/thoughts/feelings as the result of some inner failing or the failings of others.”
I agree with you to some extent. I think most people who suffer from a mental illness are desperate to find out what’s wrong with them and actively seek a diagnosis.
However, I was devasted when I found out I had been diagnosed with a personality disorder. In my opinion, it is the worst possible diagnosis, and carries so much stigma with it, that the diagnosis was a trauma in itself. For a while, I was actually convinced that I was bipolar, and in some ways, I would still prefer this label, because it implies a ‘proper illness’ and not an attention seeking waster who takes up valuable bed space.
I would prefer “Emotional Regulation Disorder” or similar, because words do matter. Especially when a future employer/midwife has a peek at your medical notes and thinks “axe” “Broadmoor” and “foster Care.”
It’s bad enough having horrible things happen to you as a child/adult and nearly destroying yourself to cope with the trauma. It’s worse to end up with a label that confirms your worst thoughts about yourself, and perhaps this is not entirely the label’s fault.
Wow I love it when people make me think and question my opinions! It’s true that there are some people who may choose/prefer/find it useful/validating/helpful/more respectful to frame their thoughts/feelings/behaviour in terms of a diagnosis of BPD. Absolutely. I’ve met a few people who read down the checklist for BPD symptoms and said, “yes, yes, yes, that’s me” with relief to have found themselves and explalanation for their distress - they could then go and buy books on BPD, their relatives could read about BPD, they could go into treatment designed especially for people with BPD. It helped them. So, you’re right, and I really don’t dismiss any of that (notice, I’ve even stopped using quotation marks everywhere to demonstrate my sincerity!)
I think that the problem is with having a label or a frame of reference imposed on one from above - I’m talking about the many many more people I’ve met who’ve been diagnosed with BPD who have been told they have BPD, who do not agree, who do not find it a useful way to conceive their distress, but who nonetheless carry that diagnosis because the system for helping people in distress happens to have the medical model at it’s foundation. This simply does not allow for people to frame their experiences in any of the myraid of different ways that would suit them better. It’s not the existence of the medical model that I’m opposed to, just it’s dominant position in mental health care.
It should be one of many options for people to understand themselves as disordered and needing fixing, but in fact it is the only one. And, though I have met some practitioners who work very skillfully in this framework and utter the phrase borderline personality disorder with the deepest respect for the person they are discussing and their experiences, unfortunately I have met many more who throw the term around as a short-hand off “pain in the ass”. It is associated with all the hopelessness of not being able to fix what’s perceived as broken, and the helplessness that this arouses in practitioners. When practitioners turn this outwards and project their own difficult feelings onto the people they’re working with, BPD simply becomes a good way to blame people for being miserable and for making others miserable, and to wash ones hands of them. So I don’t really see it as much of a choice personally not in the current climate.
Personality disorder has been seen as a “waste-bin” diagnosis by critics in the sense that it is the box into which patients who don’t fit into any of the other boxes have been thrown. As such, the presentation and experience of people thus classified can vary so immensely that it can hardly be considered a valid concept.
It may not be possible to wish BPD away (or the rest of the psychiatric classification system), but that’s no reason to stop trying to! The campaign for the abolishion (sp?) of the schizophrenia label (CASL) are working on it for schizophrenia, but why stop there?
Shrink, the problem with your argument that conceptualising it as a disorder will lead to the possibility of treatment and the benefit and improvement is that this is not a “disorder” with a great “recovery rate” is it? Being diagnosed with BPD is much more likely to mean “hopeless case” to the person and those around them then “good potential for recovery”. It means you’re broken in a way that either can’t be fixed or would be too expensive and take too long to fix because you are SO BADLY broken. Besides which, just because a doctor has diagnosed a personality disorder does not mean that the treatments available for personality disorders are what the person needs. It’s really not everyone labelled BPD that needs constant confrontation about their impact on others, extra-strong boundaries all the time, not to be given too much attention in a crisis, no medication ever because they’re not ill, and hours and hours of sitting in highly charged group settings. Some people might just need some love, warmth, nurturing, holding, hugs, yoga, gardening, meditation, children, animals, friends, therapy, moderate medication, a flexible and meaningful job, a creative outlet, and some periods of respite. That’s not about “fixing” what’s broken, it’s about learning, understanding, living and growing.
Hoboy did I open a can of worms with this post or what?
Lou, pesky, I hear everything you’re saying and I agree. Zarathustra had it bang on the money when he said that saying someone had a personality disorder was the polite psychiatric way of calling someone an arsehole. It upsets me greatly that people with BPD are marginalised and stigmatised in wider society, and then further marginalised and stigmatised in the very services they go to for help. So what’s easier - changing attitudes about people with BPD or getting rid of the label/replacing it with something else?
Neither seems a particularly easy option, but Len Bowers has done research on what kinds of nurses work most successfully with people with PD in secure hospitals and also into what they do that enables them to work so successfully. This could inform staff training. I certainly found it useful to reframe some of the behaviour that I found so very challenging to work with - like you say, pesky, think of it as survival mechanisms. But then, I often had a sneaking admiration for some of our BPD patients, particularly the more rebellious ones.
Beakie,
Thanks for your postive responses.
Personally, I would welcome a change in the BPD label.
Especially when I’ve never been admitted to a secure unit, have a Univerity degree, a reasonably successful career and have spent a lot of time working with special needs adults in a professional capacity. I
As you can imagine, this label could have potential implications for my career, which are much more negative than ‘Bioplar’ or ‘Severe depression’ could ever be.
It
The notion of untreatability is misleading. The personality may not be treatable (that’s open for debate anyway) but most of the time we’re not supposed to treat personlaities. We treat symptoms.
After all - everybody has a personlaity and that doesn’t stop most people getting appropriate help. The problem with personality disorder is that we get confused about what we’re supposed to be doing.
I have worked with many people with borderline and other personlaity disorder diagnoses. The task is always the same - work on the problems and not the personality type.
For what it’s worth
Just wanted to say, thank you to everyone for participating in this thread. I’ve found it really useful and it’s been great to have a space to have this kind of debate without getting into trouble !!!
This has indeed been one of the livelier discussions we’ve had on Mental Nurse. Thanks to all who’ve shared their thoughts.
A couple of thoughts from me:
Some on here have suggested that Borderline Personality Disorder should be renamed something else. I hear what you guys are saying, but how long would it be before the new name simply became a term of abuse like the old one? Would it simply result in the nurses on the acute ward moaning about “another bloody Emotional Dysregulation Disorder” instead?
If we’re going to persuade the powers that be to pump money and resources into services for people with personality disorders, I think there’s a good case for putting those resources into CAMHS. Admittedly I would say that because I’m a CAMHS nurse, but the best window of opportunity for treating the PD is when it’s forming in a child or adolescent, and we still have a chance to redirect them down a different road.
Alternatively, since Early Interventions in Psychosis teams are increasingly in vogue, perhaps we should look at having Early Interventions in Personality Disorders teams too, working with an age range of, say, 14 to 21, and giving them a few intensive years of psychotherapy during their formative years.
Finally, I’d just like to give my thanks to Lou and Disillusioned for giving their own personal insights on the suggestion that PDs are untreatable and that people with PDs can’t recover. As their testimonies show, both of those suggestions are simply bollocks.
Before CAMHS would get the extra resources to prevent patients to develop a personality disorder, I think you should do some research to try to find out what works in CAMHS. I’m not sure there is any yet.For CAMHS investing in the Triple P program migth be value for money http://www.informaworld.com/sm.....010~db=all and it might be worth looking at the program Colorado developed, http://www.tyc.state.tx.us/prevention/index.html.
apple> Sadly, from what I have seen, what would work best for a lot of young patients is a parent-ectomy. The cause of the problem tends to become abundantly clear at visiting hours…
Pesky student’s insight and analysis are bang on the money. As someone who is in the process of refuting the BPD label I whole heartedly agree that not only is it a dust bin diagnosis but it spells disaster for one’s self image. If you’re bright, articulate, analytical and critical of lazy pejorative name calling in the name of Mental Health ‘care’ then your in danger of having this slapped on you. It frequently becomes a self fullfilling prophecy and has catastrophic implications. It’s heavily gender biased and has more to do with how females manifest and process distree/trauma.