Mental health

Borderline Personality Disorder: Are the Helpers Actually Hurting?

Borderline personality disorder: The harmful effects of health professional stigma

People with borderline personality disorder (BPD) face a lot of challenges.  Unhelpful treatment providers shouldn’t be among those challenges, but I suspect that all too often, they are.

Learning to work with borderline personality disorder

One of my jobs is at a mental health and addictions transitional program.  While some of the staff are licensed mental health professionals, most are not.  For many of the support workers, their only formal training is a one-semester community mental health worker certificate program.  Some of these support workers do a great job, but their lack of training limits the skills and knowledge they can draw upon.

A number of clients in the program have BPD, and I think it would be safe to say that all of them have a considerable trauma history.  This may be a gross over-generalization, but in my experience, clients with BPD pose the greatest challenge to service providers, and I would like to see more service providers take ownership of that rather than shifting blame to the clients.  

I’ve been lucky enough to have worked with clinicians who were highly experienced with treating BPD, including providing dialectical behaviour therapy (DBT).  It was so powerful to see the impact this had on clients, and I learned a great deal from them.

Lack of knowledge leads to rigidity

What I see more often in support providers who don’t have that level of knowledge, skills, and experience is a rigid approach to clients with BPD that involves a focus on limit-setting, challenging (invalidating) clients’ beliefs/emotions/experiences, and establishing a clear hierarchy and power differential.  In my mind, this comes from misinterpretations due to limited understanding of how to effectively work with clients with BPD.  And my observation has been that this approach doesn’t work.

Time and time again, I’ve seen it develop into a combative relationship with the client. Yet I can’t think of a single time when I’ve known a care provider to take responsibility and acknowledge that their approach has contributed to the problem rather than the solution.  It’s always the client that gets blamed, and this ends up becoming a self-fulfilling prophecy by reinforcing stigmatized ideas.  If you treat someone like a bratty child, then it’s likely they will react like a child; I’m not sure why this is so hard to grasp.

The difference validation makes

This came to mind recently because of some interactions I had with a client with BPD.  She had approached me and expressed irritation with certain things.  It quickly became clear that she was feeling invalidated, and the irritation had nothing to do with me.  As we talked, I took advantage of every opportunity to provide any sort of validation, and it was clearly effective.  Yet this is a client I always hear other staff talk about as being difficult, and when I hear them talk about their approach with her, I think wow, no wonder you find her difficult.

It reminded me of a former client of the program, another female with BPD.  Staff often described her as game-y, and trying to negotiate around things like which meds she would and wouldn’t take.  All of the other nurses took a paternalistic, you-must-do-as-I-say approach. They found her difficult to deal with, and she often refused at least some of her meds.  

I approached everything I did with her as a collaboration, and explained my rationale for anything I was recommending.  She felt empowered, and ended up going along with my recommendations; by giving her the power of choice, I got meds into her 100% of the time.

People with BPD deserve better

It fundamentally bothers me that there are care providers who are making things worse for clients with borderline personality disorder, and instead of taking professional responsibility, they’re blaming the clients.  That’s just not cool.  Unfortunately, the rigid limit-setting types generally don’t seem to be very open to suggestions that another way could work better.  

In my current workplace culture, any attempts to rock the boat are considered totally unacceptable, and I feel powerless to bring about change.  I seem to be viewed as the nurse who is “too easy” on clients with BPD, and it really saddens me that there are people who think they need to be “hard” on that same group of clients.

I’ll put it out to my blogging buddies with BPD – have you encountered the rigid limit-setting type of care provider, and what has that been like for you?

Stop mental illness stigma; image of a hand with a dialogue box in the palm

You can find more about stigma on the Stop Stigma page.

22 thoughts on “Borderline Personality Disorder: Are the Helpers Actually Hurting?”

  1. Wow, this is so validating. I have a diagnosis of BPD (traits) along with autism (and blindness and mild mobility impairment) and was often classified as “difficult” by my former care staff and even my psychologist. In fact, she diagnosed me with dependent PD along with BPD traits (and removed my autism diagnosis) not because I’m passive (I’m not), but because I fought like a lioness for what I felt was the right care for me re my disabilities. This she thought of as manipulation, dependency etc. Well, what do you expect after 9 1/2 years in a mental institution, before which I spent only three months living fully independently, which had me fall apart? It’s my experience that most mental health providers, even those who are licensed, are clueless about the trauma history of many BPD sufferers. As for DBT, I do it now (a modifieid, individually-based course because of my autism) and I’m definitely finding it helpful.

  2. One of my friends with BPD was treated exactly like a bratty child whenever she raised questions or disagreed with a treatment plan and it always resulted in conflict. Her vs the mental health workers. She would go out swinging but was always willing to listen and try new things if people approached her the right way, but as a very intelligent woman already confused by her own feelings, being talked down to and treated as a ‘problem patient’ embarrassed and insulted her which only fuelled her insecurities.

    Validation is SO important and the approach you are taking is perfect. When I worked in a call centre for Centrelink (Australia’s social security) staff were always copping verbal abuse from irate customers, many of whom had mental health issues. It was the staff who instantly went on the defensive that would end up being screamed at, those of us who validated our customers feelings, didn’t pretend to already know exactly what a person was going through but listened and were willing to try and understand their situation were able to reassure them that we were doing our best to help and we rarely had a problem.
    xoxo Kate

  3. I haven’t been diagnosed with BPD but I’ve been told I have BPD traits and, as you know, this was the approach my former therapist ended up taking with me. It was that self-fulfilling prophecy. As I felt disempowered, I fought back harder for choice. I became the difficult client. I’m appreciative to you for being someone who does better by the people you work with.

  4. I saw this when I was institutionalized along with many other things that bothered me but of course I had no voice, I was a patient myself, a drunk, bipolar at that.

  5. One of the reasons why I am currently studying psychology or why I got certified as a CBT Therapist is because I want to contribute my mite to mental health care of the ill and challenged. Maybe out there the hospitals are even decent, here please you don’t want to see pictures. There is say one long bench in the consultation yard (not room) and two shrinks for the entire town – at the lone public hospital of our economic capital. It is still only a psychiatry unit and currently no therapist or psychologist. There are nurses and social workers but you need to see how they treat the patients. Anyway, I will start a formal internship there next month and make a better appraisal. I know anyway that I’ll treat people how I’ll want to be treated – with empathy, validation, even show some love why not. You go right on Ashley, making a difference even in one life at a time matters

  6. Fairly unrelated, now that I’m caring for my Grandma, who has unmanaged chronic pain from arthritis and I’m not yet sure what else, and who is prideful and stubborn to the nth degree and refuses most help (she’s now without much of a choice), I found this really helpful as a caregiver approach that’s effective and not harsh and harmful. Good lesson for me, thank you.

  7. I was diagnosed at Depression, a depletion of the central nervous system.
    Doc prescribed painkillers, tablets designed for a bipolar person.
    Created havoc with my body and sometimes, most days, I do too much of soul searching, seek validation and some days, just go ugh.
    Not pleasant.

  8. This is so true. Have you written any other posts on BPD and what works best for these people? I know little about the condition so even informative descriptive posts would be useful, as is first person account.

  9. “…pose the greatest challenge to service providers”. This is what kills me. They blame it on me “having a moment so do what I learned in CBT/CAT”. I’m dismissed like this a lot and as you kindly read in my social media article, am accused of behavioural problems, hatred and substance abuse!!! No wonder I feel on the verge of nervous collapse and would like to find out how others are treated. If you or anyone reading this can recommend any blogs I’d dearly love to know. Thank you, Sharon 💜

      1. Brilliant Ashley thank you so much! It’s great how many people are sharing their experiences and stories online for others to read and definitely realise they’re not alone. I’m in Scotland enjoying some countryside time with my dad 💖

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