Thursday, January 8, 2009

Borderline Personality, addendum:

I continue to feel this whole subject--of borderline personality-- is a dicey one to wade into, but I didn't want to be avoiding it either.

Part of a problem I've observed is that many extremely important and valid concerns or complaints can be dismissively pathologized as part of a "personality disorder trait".

For example, negative experiences of physicians or the hospital system need not be considered part of an individual's "pathology".

In fact, I think it is more uncommon than common for anyone to have a smooth journey through any medical care system--it tends to be laden with frustration, despite hopefully encountering some good people along the way.

Negative experiences of individual caregivers or relationships within a system need not be dismissed as so-called "splitting" (a "borderline" phenomenon)--they may be accurate and insightful accounts of having encountered a negative relationship.

The experiences may be a product of having encountered poor medical care, a poor medical system, or an unhealthy set of social structures which provide inadequate help. Sometimes an individual's complaints about these negative experiences may actually be a sign of courage, a character strength, rather than of a "borderline trait".

I think a larger view of so-called "borderline phenomena" has to do with group dynamics, as opposed to individual dynamics. If expressions of concern or frustration are met with hostile, judgmental, or inconsistent reactions, this may magnify the initial concerns or frustrations, leading to a vicious cycle. Each individual in such a dynamic may be behaving "healthily", but the relationship is not working. The relationship failure may be due to an inadequate structure, a lack of mutual understanding, communicative failure, a long history of relationship problems which biases the present point of view, tiredness or frustration on either side, or an insurmountable cultural gap. This reminds me of some of the conflicts between nations that go on today, in which each nation's "point of view" is understandable and valid, but the relationship fails, sometimes in a very destructive way, sometimes leading to an "arms race." Ironically, in psychiatry, such borderline relationship dynamics may occur involving the very individuals who are trying to be relationship mediators. My point here is that sometimes it is not the individual who has a "borderline personality disorder", but the relationship, or the system, which is suffering from "borderline dynamics".

An author on the subject of borderline personality I consider important is David Dawson. Title: Relationship Management of the Borderline Patient, Brunner/Mazel, 1993

I do find him wise and frank. He challenges some of the the professionally self-indulgent dogmas about psychotherapy, psychiatric hospitalization, and psychiatric medication, dogmas which may not apply to every situation, dogmas which may well, in some cases, aggrandize the "healing power" of the system or the therapeutic process, dogmas which deserve a generous dose of humility in order to more soundly be helpful. He describes numerous dramatic "case vignettes", with much needed attention given to the consideration of process and relationship dynamics. Many of his ideas about the vignettes I disagree with, but the book could open a forum for debate and discussion.

But-- I find his style at times too cynical and lacking in gentle warmth, to affirm it strongly. In fact, Dawson's ideas I think at times have been misapplied in the medical system, used as part of a tactic to prematurely discharge some patients from hospital or from other follow-up care. Yet, I think Dawson's views are important to hear, at least as the starting point for a debate.


Anonymous said...

I'm glad that you're writing about this here.

One thing that bothers me about the whole "borderline thing" is the motivation behind the diagnosis. If the goal of psychiatric diagnosis and teratment is ultimately to help patients, this makes me question why some clinicians apply personality disorders. I don't doubt that these diagnosies could be beneficial--in some cases, for some patients, etc--but I do not see that these diagnoses are always used "for good".

It seems to me sometimes that Axis II diagnoses-- particularly "Cluster B" diagnoses-- are used as a kind of warning to future clinicians about the supposed volatility/ unreliability/ etc of certain pateints. Sometimes it seems-- and you kind of allude to this in your post-- that the diagnosis is used as a way of dismissing legitimate patient concerns or unhappy experiences with the medical system. Sometimes it seems to be used as an excuse to deny services, or end treatment, or justify a cold and rigid therapeutic style-- I guess under the guise that these patients need "boundaries"--that just seems to make the situation worse.

I do think that sometimes the term "bordelrine" is used as an epithet--I'm reminded of one article I read in which ti was referred to as a "sophisticated insult"-- and sometiems it seems to me that the problem is that this just serves to emphasize the distance between a clinician and a patient--or maybe it just highlights the power imbalance--in any case, sometimes it DOES seem to me that this diagnosis can be used as a kind of punishment or threat or (at the very least) an insult.

I guess what also bothers me is the fact that so many patients who have this diagnosis in their charts are completely unaware that the diagnosis has been made. I wodner sometimes if this diagnosis is something that should only be documented in a chart after a patient has given some kind of informed consent! Your chart follows you everywhere, and even if many (most?) clinicians treat Axis II diagnoses with respect, the danger seems to be to give any further ammunition to future clinicians who perhaps do not have such generous views towards patients with these diagnoses.

I can see that the idea of asking patients for "permission" to document a psychiatric diagnosis is problematic. I'm not comfortable with this idea when applied to Axis I diagnoses. But I do wonder sometimes if the threat of an Axis II diagnosis does prevent patients (particularly patients who might have some kind of familiarity with DSM language, e.g. most of Psychology 101 students!) from being open with clinicians about various psychiatric symptoms.

(I personally have found myself refusing to answer some questions posed to me by clinicians in a consultation if it seems that the questions are trying to establish a BPD diagnosis...I am certainly more open to admitting to "borderline phenomena" once I am clear about a clinician's philosophy about Axis II disorders).

Sometimes it seems to me that all of this talk about "mental illness" and "stigma" among mental health professionals is meaningless given the tendency I have seen for psychiatric clinicians--and health sceinces students--to hold very biased and hurtful views of patients with Axis II diagnoses. (As a former health sciences student I was ALWAYS amazed at how many people could express real empathy for pateints suffering from schizophrenia...depression...eating disorders...etc, yet they were completely unable to extend this empathy to patients who were "borderlines".

Similarly, I have noticed that many health sciences students I have met are more tha n willing to accept that they or someone they loved might now or someday suffer from depression/ schizophrenia/ an eating disorder/ etc. But it has seemed to me sometimes that personality disorders are somehow treated, even among ehalth care professionals (and students) as some kind of moral failing, and theerfore that these diagnoses cannot possibly touch them. I remember once listening to students talk about family memebrs suffering from various Axis I conditions...and when the discussion turned to AXis II conditions, it seemed that it was only the "crazy roommates" or the "abusive ex-boyfriend" who were potentially afflicted with these disorders!

Sorry for the long post-- I don't mean to ramble!--I guess this is a loaded topic.

GK said...

Thank you for your comment.

There is much work to be done at "de-stigmatizing" these issues.

Another angle on this issue is the converse--some clinicians or therapists are so frightened of discussing this topic, or so averse to considering the use of the term "borderline", that it just never gets discussed at all--or patients who may benefit from some of the knowledge about "borderline personality" and its effective treatments do not get very good care, because they instead receive diagnoses of "bipolar II disorder" or "psychosis NOS", etc., and may therefore be reflexively admitted, sometimes on an involuntary basis, to hospital stays or intensive medical therapies which end up doing them further harm.

Part of the solution, I think, is perhaps to be wary of ANY labels, always. A problem deserves to be heard, an attempt should be made to understand and help, perhaps a past history may guide understanding, but perhaps labels can adversely affect care.

In other areas of medicine, for example, if someone is labeled--correctly--as "that guy with unstable angina"--it may more quickly guide a new emergency clinician to check for a new heart attack -- BUT it may also lead that same clinician to miss checking for the possibility of a bleeding ulcer, or pancreatitis, etc. Labels can be useful, but also can have a tremendous power to reduce our openness of mind, and therefore our ability to help best.

But in any case, I do recognize that categories such as "borderline" can applied in a way that is hurtful or inappropriate. I have seen this happen. We need to continue to work on ways to mend this problem.

Anonymous said...

I think my original comment got eaten by the internet (Server error). Ignore if you recieved this already.

3 questions:

When you write:
"...some clinicians or therapists are so frightened of discussing this topic, or so averse to considering the use of the term "borderline", that it just never gets discussed at all..."

1. Do you tell your patients you are diagnosing them with BPD?

2. If so, how do you do it in a way that respects both a person's right to know their medical history and a way that protects them from future rejection/dismissal by other healthcare professionals?

You also said:

[In a relationship]"...If expressions of concern or frustration are met with hostile, judgmental, or inconsistent reactions, this may magnify the initial concerns or frustrations, leading to a vicious cycle. Each individual in such a dynamic may be behaving "healthily", but the relationship is not working..."

3. In this example is it the individual receiving the expressions of concern who is reacting medically pathologically (I am meaning pathological define a medical assessment vs. a value judgement), or the person reacting?

I am confused because down the page you mention,

"..." Ironically, in psychiatry, such borderline relationship dynamics may occur involving the very individuals who are trying to be relationship mediators..."

Anon too

GK said...

1) Yes. I believe, at this point, in very frank discussion about such things with my patients. I also admit that I not always right. I also am not one who has ever been strongly attached to the idea of labels or pigeon-holing, etc. Yet I guess I try not to vacillate too much either (yet, here I am vacillating to some degree, but in a way which is characteristic of myself!)

Many types of understanding about a person's life, difficulties, and problems, may only come from a long period of time spent trying to understand (by both patient and therapist), and I certainly believe that a single interview is an absurdly fragmentary course for any sort of understanding to form.

2) In terms of a medical record, I believe it is best to be reserved about diagnostic labeling, and to express a wide "differential" in conjunction with a description of the events that have occurred. The most effort, I think, should be spent in obtaining a clear account, of the events or symptoms that have occurred, rather than whatever someone's opinion has been of them. Also, I believe the medical record is the patient's, and is certainly for the patient, and therefore entries to a medical record should occur with the patient's knowledge.

I do believe that descriptions of past events can help guide future care, but I also recognize that descriptions of past events can be biased or give rise to misleading conclusions. These facts should themselves be included in a medical record as a standard practice.

With respect to the potential of rejection/dismissal -- I claim -- very strongly -- that there is no label that would give rise to rejection/dismissal from any good therapist.

If there was such a therapist who would dismiss based on such information -- it is better not to have worked with that person in the first place.

I strongly believe that there are MANY very good therapists inside and outside the medical system, who do not reject/dismiss, neither on the basis of any sort of diagnostic label, nor on the basis of any other element of history.

3) My point here was that it is the "relationship" (not either individual party) that can be "pathological", due to misunderstanding, cultural difference, biases, past experience, etc. Yet, in an evolving such dynamic, BOTH parties can end up behaving regrettably, or in a way which does not help (one can look at global politics for examples).