“Borderline personality disorder” (often shortened to “BPD”) is strongly associated with crisis: a subjective and overwhelming experience which can include difficulties with emotions and perceptions, and may even lead to self-harm and attempted suicide.
Frequently, it leads people to seek help from health, social care, and emergency services. However, crisis care is not always what it should be.
“BPD” is a common but controversial psychiatric diagnosis applied to approximately 1% of the UK population. Previous estimates suggest that between 4% and 10% of people with the diagnosis may take their own life.
People diagnosed often experience difficulties such as becoming overwhelmed by their emotions, behaving impulsively, and having issues in relationships with others.
These same individuals have often been hurt by the world. “BPD” is strongly associated with experiences of trauma and adversity, including physical, sexual and emotional abuse, as well as neglect. This is why, rather than seeing this behaviour as “difficult”, we should view it as understandable adaptive responses to adversity.
The horrific salt in the wound is that not only have people been hurt by the world, it is sometimes by those who should have cared for them.
When, as a result of this, people experience crisis and seek help, some have difficulty accessing care and are unable to get the help they need. Even when they do get help, they can have either positive or negative experiences, and there is a danger that they may be let down again – only this time, by the professionals who are paid to look after them.
Staff can lack sympathy and even dislike those in their care
Research tells us that staff can lack sympathy for and even dislike those with the diagnosis. Sometimes professionals hold beliefs that they are manipulative, time-wasting and attention seeking people, and actively avoid them. This chimes with my previous experience as a mental health nurse, often hearing colleagues sigh in frustration as people with the diagnosis were admitted to hospital.
There are many human factors which can influence care. Services may not have adequate resources, professionals may have varied education and views. Differing opinions can lead to conflicts within staff teams about how best to provide care.
It can be argued that any ‘personality disorder’ diagnosis that locates the problem inside the person and not with what happened to them is not only inaccurate but hugely unjust
Furthermore, it is understandable that staff themselves may experience distress while working with people who hurt themselves and want to die. Their very human anxiety can influence the care they deliver, sometimes being driven by their own fear and helplessness rather than what might be best for the person with the diagnosis.
A reflective space for professionals to support each other, such as clinical supervision, is recommended but not always utilised or available. Staff need the appropriate education, understanding, resources and support to be able to deliver care effectively, and this is something for all care providers to review.
Non-caring care
As people with a “BPD” diagnosis have often experienced difficult relationships and good mental health care is all be based around creating therapeutic relationships, it is essential this is given appropriate consideration.
Patients describe “non-caring care”; being treated like a diagnosis, and responses overlooking their thoughts and feelings while focusing solely on their behaviour. This behaviour focus lacks the empathy and curiosity which can help people better understand themselves.
Working with the risk of suicide is inherently complex. People can have their responsibility removed (for example, being detained under the mental health act) but sometimes with a paradoxical demand that they take more responsibility for themselves.
Compounding all of these issues is the fact that the label has a powerful negative stereotype attached, and people often experience stigma and discrimination. While poor care may not be universal, it is certainly not rare.
Treating people like humans inspires hope
Positive experiences are not the result of elaborate interventions, but primarily based in humanism; having contact with professionals, sharing in decision-making, being treated like a person and having care focus on their underlying emotional distress, which inspires hope in their recovery.
It would be an important first step for care to always start with empathy, and for all caregivers to truly see people as human beings rather than labels
Understanding what has happened to people in their lives helps us to make sense of the way they feel and the things that they do. It can be argued that any “personality disorder” diagnosis that locates the problem inside the person and not with what happened to them is not only inaccurate but hugely unjust.
The use of inverted commas in my writing around the “BPD” psychiatric label is deliberate. It is used to acknowledge important debates. The distress people experience is very real, though it is not due to having a disordered personality.
The BPD diagnosis is of no real use
There are so many different presentations of “BPD” and subjective experiences that the diagnosis is actually of no use. Care should see the person and focus on their needs in the moment, moving beyond behaviour management to exploring and supporting people with their internal experiences, their thoughts, feelings and mental states.
The best feedback I’ve received from people with the diagnosis has been about the simple human connection: “I always felt like you cared” and “I felt like I was talking to you, not the NHS”.
The fact that this may not be every patient’s experience strikes me as a tragedy of the current mental health system.
It would be an important first step for care to always start with empathy, and for all caregivers to truly see people as human beings rather than labels.
There is much work for everyone to do to improve crisis care for people diagnosed with “borderline personality disorder”, and useful progress will likely include letting go of the label altogether.
Dan Warrender is one of Robert Gordon University’s mental health nursing lecturers and co-founder of Mental Health Movie Monthly