Am I an expert on this topic? Not exactly; I’ll let you decide for yourself. Fair enough?
Hence “My Take,” such as it is:
I do have some small experience. I’ve usually get along rather well with people unfortunate enough to contend with this dark label. We work well together. That’s rather unusual, in my experience.
People’s experiences of mental illness only partly reflect anything between their own ears. They also experience others’ reactions to them: to their behavior, speech, AND the labels they carry. Of course, like any human beings, they also react to others’ reactions to them. Who doesn’t? Such is social life, cause and effect churning like a pot boiling.
This social dynamic explains why I’ve learned to ignore Borderline at work, as best I can. I pretend there is no such thing, because it causes far more clinical harm than good. I acknowledge people, trauma, suffering, symptoms: always. Just not Borderline.
Over the years, I’ve occasionally found that my instincts and experience have produced ideas beneficial to both patients and nurses. Well aware of my own limited academic klout, when I first thought to teach others, I started searching more credible sources to perhaps corroborate my findings. It has been a gratifying and useful experience.
As an example, I once attended a lecture by Dr. George Vaillant. He spoke on his paper, The Beginning of Wisdom is Never Calling a Patient Borderline. Dr. Vaillant described Borderline as “countertransference more often than… clinical precision.” In other words, it mostly gets used in clinical work as a slur, a pejorative, a warning to expect unpleasantness, wasted time and energy, and failure. Diagnosis, in the western medical model, is useful only in that it offers clarity regarding prognosis and treatment. I agree with Dr Vaillant that Borderline Personality Disorder fails by that measure. As a label, it does more to lessen the odds of a treater offering anything helpful than it does to improve them.
I don’t mean to argue that this ailment is a myth. People have real symptoms, clearly. Yet clinical ideas should be judged primarily by their usefulness, by the way they improve patient care. By this measure, Borderline Personality Disorder seems to fail in most cases. Instead of benefit, it offers tremendous stigma and suffering.
Dr Vaillant argued for a gentle and understanding approach to all patients, especially when it comes to their sore spots. It makes sense, doesn’t it? People are tempted to defend themselves as best they can when we attack them or push their buttons. If we attack them or push their buttons, whose fault is the response? Who needs to change their ways?
For many years, I’ve often seen people unwittingly push patients’ buttons, kick their shins, attack sore spots, then blame patients for responding poorly to such treatment and avoid learning anything at all. THAT refusal to accept any responsibility or reason to learn, I submit, is the primary reason such staff members never achieve better clinical results. To learn nothing and change nothing: it’s the ultimate recipe for stagnation and bitter failure. Such decisions have absolutely nothing to do with patients’ illnesses. To blame patients for our own failures is unwise, unfair, and completely impractical. Those who act this way deserve the suffering and failure they experience at work; they have earned it. Shocked? Clinicians routinely judge patients labelled Borderline exactly that harshly. It seems only fair to apply the same standard to all involved.
Overwhelmingly, what others have described as “manipulative,” “dramatic,” “inappropriate,” “Cluster B” or just pain “being borderline,” I’ve experienced as no big deal, or as people doing their best under extremely difficult circumstances. I react accordingly, and such problems abate. Others offer the standard fare and elicit a far less pleasant presentation. Who’s right? I generally bet on approaches with the best track record. If what you “should” do fails, or what you’ve “always done” fails, then you’re mistaken, end of story. It’s time to find another way.
Let’s go over the diagnosis in more detail: DSM-5 diagnostic criteria from the American Psychiatric Association.
Forget about Axis 2. As of DSM-4 it still existed, although it was mostly used among nurses and other providers as a vague unofficial adjective. Patients, so the shift reports went, “were Axis 2” or were “being Axis 2.” It was a way to say in code that a patient was a pain in the ass: an insult and a warning. People still use such langauge, even though DSM-5 eliminated the entire Axis system. I generally counsel patients to give our current diagnostic system no more respect or concern than it merits; we have a long, long way to go. The beginning of wisdom is knowing the limits of your knowledge. These days we see more confidence and bluff than wisdom in mental health practice. Humility is best.
Keep in mind that in DSM-5, folks with Borderline Disorder live next door to those with Antisocial Disorder: serious criminals, in other words. The stigma is striking, isn’t it?
That said, here are the possible symptoms, from the Desk Reference DSM-5:
“1. Frantic efforts to avoid real or imagined abandonment…”
“2. A pattern of unstable and intense interpersonal relationships… alternating extremes of idealization and devaluation.”
“3. Identity disturbance: markedly and persistently unstable self-image or sense of self.”
“4. Impulsivity… self-damaging.”
“5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating…”
“6. Affective instability… marked reactivity of mood…”
“7. Chronic feelings of emptiness.”
“8. Inappropriate, intense anger or difficulty controlling anger…”
“9. Transient, stress-related paranoid ideation or dissociative symptoms.”
Let’s discuss the powers of expectations a bit. When I trained with Social Workers years before I became a nurse, they had us do an exercise. They had index cards with adjectives written on them; the ones I remember now were “pretty” and “angry.” They gave us each a card, taping it to our backs, so everyone else could see it, but not us. Then we mingled a few minutes. I watched a lady who got the “pretty” card. Such bliss! She was the Belle of the Ball, and it clearly brought out her good side with people: smiling, animated, confident, pleasant. Meanwhile, every time I spoke to someone it was like I was in trouble somehow, a problem, a threat. It really got aggravating, and quickly! I got sarcastic, defensive, and – you guessed it – angry.
Guess which card was on my back?
Social expectations have tremendous power: they make highly self-fulfilling predictions, all the time. That’s normal human nature: nothing to do with illness. Imagine meeting people with those 9 symptoms listed above, written on your back. Nine cards – nine! – imagine that! Imagine knowing, from years of experience, what to expect? Knowing you’ll get blamed for the way people treat you…
That’s what happens every day when a nurse gets report on a new patient, “that Borderline.”
It’s a problem, and one that has nothing to with illness. It’s entirely a social problem, and we do well to keep it in mind. We contribute – and we have the power to make it better, simply by addressing ourselves: our reactions, our assumptions, our behavior.
It’s power, that: power, and doing good.
Not bad, yes?
So there it is. I hope it’s been helpful!
As always, I would much appreciate any feedback:
Is such content useful?
What’s missing? Wrong?
What can you tell us about it?