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.
Skills in working with BPD
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 their skills and knowledge.
A number of clients in the program have BPD, and most, if not all, 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.
Rigidity from lack of skill
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.
This came to mind recently because of some interactions I had with a client with borderline personality disorder. 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.
Not good enough
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?
You can find more on mental illness stigma on the Stop the Stigma page.
A Brief History of Stigma is the upcoming new release from Mental Health @ Home Books. It looks at the nature of stigma, the contexts in which it occurs, and how to challenge it most effectively.
Visit the book page for tips on how to be an effective advocate.