The Beginning of Wisdom is never calling a patient Borderline

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I’m forty pages into writing my very first book, and I’m cheating a little, using the some of the same material for blog posts. Efficient!

Anyway, I’ve been writing about Reciprocity, a topic for another post as it’s dear to my heart. Basically, it refers to the human instinct to repay gifts. So I was reviewing gifts nurses could give patients to help build rapport and cooperation. And I came to how to give a gift to patients with a bad reputation or you don’t like or expect to be difficult and frustrating, which brought me to one of my favorite clinical topics, Borderline Personality Disorder. How can caregivers do better? What gifts can they offer?

At a minimum, caregivers, manage your expectations. First, hide them VERY well. As most of us have limited acting skills, don’t try to fake anything when you have strong negative feelings or expectations for a patient: go for a poker face instead, blank, neutral, professional. It takes practice but it’s far easier and more honest than trying to generate something fake.

How is this a gift? Trust me, when a patient has a bad reputation or a stigma-laden diagnosis like Borderline, they meet person after person who in often not so subtle ways shows their contempt. If you show blank respect, that’s a marked improvement. At my hospital we have a trauma unit loaded with people diagnosed Borderline. I used to work there and work on a unit that accepted patients no longer welcome on the trauma unit. I’ve generally got along with such patients rather well and enjoyed my time with them.

I started out with little more than the poker face thing. Then I took it a step further: for clinical interaction purposes, I pretend Borderline doesn’t even exist, that such patients have a traumatic history and symptoms of trauma, depression, and/or anxiety. It works very well! And there’s actually some scientific basis for such an approach.

First, social psychology research shows that our expectations towards other people have surprising power in that they’re 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. Offer stigma, you get self-fulfilled “proof” it was accurate. At the same time, a “borderline’s” negative treater expectations influence you negatively, completing a never-ending cycle, a social dynamic of pain for all involved. You both give, you both react. You both create the results. Stigma is a social thing. I expect such interactions to go well, and it makes a crucial difference. And they DO go well, rather better than most people experience.

Second, psychiatrist George Vaillant makes a strong case in his paper, The Beginning of Wisdom is Never Calling a Patient a Borderline (Journal of Psychotherapy Practice and Research Volume 1 Number 2 Spring 1992 117 – 134.) I refer to it from time to time and teach from it. Dr. Vaillant doesn’t argue that such patients don’t have real symptoms, he simply argues that the diagnostic label does them more harm than good.  Some diagnoses, especially those once classified as Axis 2 (DSM V eliminated the Axis system) often reflect treater frustration more than anything else. “Borderline” and especially “borderline traits” are often no more than insults, code for “I don’t like this person” or “she’s a real pain in the butt.” How often have I heard staff members disparagingly say “they’re so borderline,” “they’re Axis 2,” or the like? It’s often an ugly slur in respectable clinical camouflage, the exact opposite of scientific or objective. Such stigmatic labeling is not only hurtful: it’s costly too, as we’ve reviewed. It hurts all involved.

Years ago, having seen a talk by Dr. Valliant, I tried an informal experiment. Without telling anyone, I pretended that all the Personality Disorders don’t exist. Based on their individual symptoms, I pretended patients suffered from depression, anxiety, trauma, etc.: no Axis 2. I tailored all education and counseling accordingly. No negative expectations, no judgment. 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 misunderstandings 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. They were about stigma. Often enough, when a patient gets in trouble, the primary trigger is another person pushing their buttons. Sadly, that trigger person is often a professional caregiver. To the contrary, my new approach made things far better and I’ve made it a permanent part of my clinical toolbox.

Sad as our current state of affairs can be, still, it’s good news! How? Whenever imperfection exists and gets recognized, it becomes an opportunity for improvement.

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 are tempted to avoid owning their mistakes, to see them as threats. This different approach turns our mistakes into pure gold: places from which we can improve clinical outcomes and lives. Opportunities! Stigma-busting helps all involved.



  1. This topic prompts me to ponder the many ways that society uses labels to impact people negatively. Most people must bristle at being labeled, particularly when they can correctly perceive how it impacts them in negative ways. And there are so many subtle ways that people can be, and are labeled. I applaud your initiative to deal with a particular example and hope it leads many readers to recognize and react positively to other examples.

    Liked by 1 person

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