By Matthew Towicz
Personality. It’s a big deal. It develops in our early years and persists across our adult life, governing our daily interactions through to our long-term relationships.
So why is it, that when confronted with disorders of personality, especially borderline personality disorder (BPD), we as clinicians are quick to disregard patients as just being ‘difficult’ or ‘causing trouble?’
Any student assigned to an inpatient mental health unit has no doubt seen their fair share of BPD. It accounts for 20% of psychiatric inpatients at any one time in Australia, despite the community prevalence sitting at 1.4%.
This poses a challenge, because people with BPD are, by definition, complex. Emotional dysregulation, unstable relationships, and often a background of childhood trauma are features of the diagnosis.
Establishing a working therapeutic relationship is difficult from the outset. Which is why carrying preformed ideas and stigma into the interview room does no favours.
Yet, despite best intentions, it does happen. Terms such as ‘manipulative’, ‘hateful’, ‘angry’, ‘non-compliant’, and ‘not sick’ are commonly expressed by doctors in reviews on this subject. Research has demonstrated that nurses show less empathy in hypothetical scenarios involving patients with BPD, compared to patients with other mental health diagnoses. To be wary of Patient X because they will ‘lie’ and try to ‘split the team’ is common advice to receive on the ward, sometimes even before the patient is seen!
The evidence tells us that clinicians are more likely to distance themselves from their patients with BPD. However, patients with BPD are sensitive to perceived neglect, and this is likely to have counterproductive outcomes for the person, and the therapeutic relationship. This in turn leads to frustration in the clinician, and so the cycle self-perpetuates.
We know that if we can increase clinicians’ skills in this area, provide them with appropriate support and supervision, and break down the myth that BPD is ‘treatment resistant’, we can increase their confidence and reduce stigma. Interventions as short as three hour programs are shown to be effective in this regard.
The end result is patient interactions centred on providing education, respect, and hope, which ultimately can reduce self-harming or suicidal behaviours.
Ways to rename or re-classify borderline personality disorder have been raised, but these alone will not reduce stigma without clinician education and support.
The question of whether we should formally diagnose BPD at all has also been raised, but the importance of a diagnosis is that it lays a platform for education about one’s own mental health to begin. Education leads to realistic, but still hopeful expectations, as opposed to confusion and frustration.
The mortality rate of BPD due to suicide is up to 10%, yet we have specific psychosocial interventions with favourable long-term outcomes. This is as good an argument as any to ensure we properly equip our mental health services in order to protect ourselves and our patients from stigma.