BPD: Are the helpers actually hurting?

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 they 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 behaviour 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 a 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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18 thoughts on “BPD: Are the helpers actually hurting?

  1. Astrid says:

    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. The Colour Of Madness says:

    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. KD says:

    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. Revenge of Eve says:

    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. Marie Abanga says:

    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. Ashley says:

    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. sunshinysa says:

    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. my dream walden says:

    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.

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