A decade or two ago, I attended a talk at McLean Hospital by psychiatrist George Vaillant. He discussed his paper, The Beginning of Wisdom is Never Calling a Patient a Borderline. I refer to it from time to time and teach from it. Here are three of the lessons it offers:
Some diagnoses often reflect treater frustration more than anything else. “Borderline” is often no more than an insult, code for “I don’t like this person” or “she’s a real pain in the butt.” How often have I heard staff members say: “they’re so borderline,” “they’re Axis 2,” or the like? It’s often an ugly slur in respectable camouflage, the exact opposite of scientific, objective, or diagnosis. They’re not only hurtful: they’re costly too.
I often work with people with trauma histories and Borderline Personality Disorder diagnoses. I usually get along with these folks just fine, contrary to their nasty reputation. Why? What do I do differently than other nurses? I can think of two things.
First, my expectations are different. Our expectations towards other people have surprising power: they’re surprisingly self-fulfilling. If you expect someone to be wonderful, it steers them towards acting wonderful. If you expect hostility, you get it. If you expect stereotypical “borderline” behavior, you get that. At the same time, a “borderline’s” expectations influence you, completing a never-ending circle, a social dynamic. You both give, you both react. You both create the results. I expect each interaction to go well, and it makes a difference.
LESSON ONE: REPLACE YOUR NEGATIVE SELF-FULFILLING EXPECTATIONS
Second, I react differently to patient speech and behavior. I intentionally control and shape my reactions: patient and friendly, without anger in response to inflammatory words or behavior. I assume people have legitimate gripes – usually easily confirmed – and that everything they do makes sense from their point of view. I set out to make sense of it, to find common ground.
Years ago, I tried an informal experiment. Without telling anyone on the unit, I pretended that all the Personality Disorders don’t exist. Based on their individual symptoms, I pretended patients suffered from depression, anxiety, trauma. I tailored all education and counseling accordingly. No negative expectations, no judgement. No flawed characters: just people who suffered.
What do you think happened?
Patients appreciated it, cooperative and enthusiastic. Things went smoother than ever before. Without all the negative expectations and hostile reactions that follow these people like shadows, some of their symptoms disappeared as well. Their symptoms weren’t just about them: they were also about how others interacted with them. Since then I’ve found similar effects across the diagnostic spectrum. Often enough, when a patient gets in trouble, the primary trigger is another person pushing their buttons. Sadly, that trigger person is often a paid caregiver.
It’s good news! We can change our own behavior far more readily than we can convince someone else to change theirs. If we trigger another person’s symptoms somehow, we can learn new ways to interact and exert a positive influence indirectly. I’ve found it works rather well, and makes clinical work far easier and more fun. Usually nurses avoid owning their mistakes, see them as threats. This different approach turns our mistakes into pure gold: places from which we can improve clinical outcomes. Opportunities!
LESSON TWO: MAKE YOURSELF A POSITIVE INFLUENCE AND ENJOY THE RESULTS.
People often interpret what you offer them far differently than you do. What seems to you reasonable and helpful might seem completely different to them. Such misunderstandings happen commonly in all walks of life: even more so with people diagnosed with personality disorders. Such people have learned to expect attacks, derision, and disdain from health care workers. They’ve learned to defend themselves, and to expect to need to defend themselves often. Such self-defense often comes across to others as an unreasonable attack or other misbehavior.
If we respond to such self-defense by habit or instinct, as people usually do, we continue or escalate the cycle of misunderstandings, hostility, and pain. We make ourselves part fo the problem.
If we learn to do better, we can improve the results dramatically. Distrust,misunderstandings, self-defense, and misbehavior all escalate under stress, regardless of illness. If we offer patients a predictable, supportive, nonjudgemental, benign persona, safe, calm, and unthreatening, then we cut many triggers to self-defense. Soon enough, being so obviously safe leads to less of the troublesome self-defense. Everyone benefits.
LESSON THREE: DON’T OFFER WHAT COMES NATURALLY. MAKE THE SITUATION BETTER INSTEAD.
Practice and refine your approach based opn these proven lessons. Soon you’ll find difficult patients become less difficult. Enjoy!
Dr Vaillant’s paper was published in 1992 in the Journal of Psychotherapy Practice and Research.