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Borderline Unhelpful

When the Helpers Do More Harm Than Good

Borderline personality disorder (BPD) has tremendous stigma associated with it. That stigma doesn't just come from people who have limited knowledge of the condition, it can also come from health care providers.

I'm a mental health nurse, and I work at a concurrent disorders program for people with mental illness and addictions. Many of the staff there are support workers who have very limited formal training. Even a lot of the professional staff haven't been out of school for a long time and haven't had the opportunity to develop the specialized knowledge and skills required to provide the most effective care for clients with BPD.

However, throughout my nursing career, I've found that it's not uncommon for care providers with limited skills in working with clients with BPD to end up having an effect that's more counter-therapeutic than therapeutic. The clients are able to sense that they're not getting treatment that's responsive to their needs, which brings out more maladaptive coping skills, which then further reinforces the professional's view of BPD clients as manipulative and difficult. On the other hand, though, I have worked with some colleagues who were very well trained and did an amazing job working with clients with BPD.

When I was first hospitalized for major depressive disorder, it was a very difficult experience for me, to say the least. Having no say in my treatment felt profoundly disempowering. All I could do was fight back, which meant that the treatment team saw me as a difficult patient. As a result, I was given a diagnosis of borderline personality traits. However, had the psychiatrist done his job competently and considered whether these supposed BPD traits were consistent and pervasive throughout my adult life, he would have realized that was not the case. Instead, he made a stigmatized judgment, because I was a challenging patient and, in his mind, a person that was indicative of BPD.

The pattern I tend to see most is that care providers with limited expertise will adopt a very rigid approach to dealing with clients with BPD, and they will set strict, arbitrary limits. They will also challenge what clients report, and in doing so invalidate their experience and establish a clear power differential between staff and client.

Limit-setting is important, as part of BPD is experiencing challenges establishing effective limits, but it's also important to do so in a way that is actually therapeutic. For providers with limited training, they may not grasp the nuance of this.  This can often end up sparking confrontation, which then becomes a source of considerable distress for the client. When this happens, far too often I see the care provider blaming the client, which then further reinforces the stigma and perpetuates the same behaviour patterns. It puzzles me why it's not easier for people to understand that if you treat someone like a child, chances are their reaction will live up to that.

It's unfortunate that more care providers don't have the insight to recognize that their behaviour contributes to the BPD client's responses that they see as problematic. In dialectical behaviour therapy (DBT), the gold standard treatment for BPD, supervision is built right into the therapy model so that therapists are reviewing their sessions with a team member and identifying any of these issues that they might not be seeing themselves. Unfortunately, in more acute care settings this supervision model doesn't tend to exist.

My experience has also been that care providers in the school of strong limit-setting sometimes view any deviation from that approach as undermining the staff team. On multiple occasions, I have been accused of being "too easy" on clients and not following the team approach because I choose to use a more DBT-informed, client-centered approach that emphasizes validation. Unfortunately, what's actually best for the client seems to be totally overlooked in favour of what is thought to be best for the staff.

I had one former patient that many of the staff described as difficult, and gamey regarding which of her meds she would and wouldn't take. Other nurses would take a very paternalistic, hard-line approach with her, which would result in considerable conflict and the client refusing meds. I took a DBT-informed collaborative approach and explained why I thought my suggestions would be helpful for her. She always ended up taking her meds. Yet even though my approach had the best outcome for the client, my approach was considered to be the wrong one by many of my colleagues.

While mental health professionals providing therapy such as DBT for clients with BPD are likely to be well-versed in effective treatment of the disorder, care providers (both professional and unlicensed) working in other areas of mental health care may not have a high level of training or experience. I think it's essential for health care providers to take responsibility for their own learning and make sure that they have the tools to provide the best possible care rather than simply perpetuating stigmatized approaches that clearly aren't working for the clients. If care providers are unhappy with a client's response to their approach, it is their responsibility to reflect on the suitability of their own actions. People with BPD have enough stigma to deal with already without having stigma from health care providers layered on top of that.

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Borderline Unhelpful
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