People with borderline personality disorder (BPD) face a lot of challenges. Unhelpful treatment providers shouldn’t be one of them, but I suspect this is the case more often than it should be.
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 range of skills and knowledge they have to draw upon.
There are a number of clients with BPD in this program, and I think it would be safe to say that all of these individuals have a considerable trauma history. This may be a gross over-generalization, but in my experience that 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 in working with clients with BPD and providing dialectical behavioral therapy (DBT). It was so powerful to see them in action and the impact this had on clients, and I learned a great deal from them.
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 (i.e. invalidating) clients’ beliefs/emotions/experiences, and establishing a clear hierarchy and power differential. In my mind this comes from misinterpretations arising from limited understanding of some of the principles of working with clients with BPD. And my observation has been that this approach doesn’t work. Time and time again I have seen it develop into a combative relationship with the client, but I can’t think of a single time when I’ve known a care provider to take responsibility and acknowledge that by using this type of approach they have 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.
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 I could find 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 often 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, and 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.
It fundamentally bothers me that there are care providers out there who are making things worse for clients with BPD, and instead of taking professional responsibility they are 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?
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