Borderline personality disorder and back-foot medicine

By Keyur Doolabh

It’s becoming generally accepted that mental illnesses are not under our control – they’re not something we can just snap out of. But even among many mental health workers, there’s a condition where we seem slow to realise this: borderline personality disorder.

We’ve all probably met someone with BPD, even if we didn’t realise it at the time. It mainly affects women, and often those who have a history of being abused or neglected – so much so that some mental healthcare practitioners have called for it to be classified as a subtype of post-traumatic mental health disorders. Because of their traumatic pasts, these people often have a strong feeling of emptiness and an unstable sense of self, connected with emotional instability, very black-and-white thinking, intense fear of abandonment, and impulsivity, including impulsive suicide. In fact, BPD has one of the highest rates of suicide of any mental illness.

Despite this, many of the psychiatrists, psychiatric nurses and psychologists I’ve come across get very frustrated by people with BPD. I’ve heard comments like ‘I have no time for borderline people,’ ‘they just get under my skin,’ and ‘if they want to kill themselves, that’s fine.’ These three comments come from three different clinicians, and are just the tip of the iceberg of what I’ve heard during my short time on psychiatry. It seems this problem is fairly widespread rather than being isolated to a few people.

Some clinicians have argued that it’s actually good for patients when their behaviours and complaints aren’t taken too seriously, because it teaches them that their attention-seeking behaviours aren’t going to be effective. But the literature disagrees: these maladaptive behaviours are the only way people with BPD know of communicating and coping with distress. If it doesn’t get them the help they’re after, they continue to escalate the behaviour. When one of these behaviours is impulsive suicide attempts, ignoring these people to teach them a lesson sounds like a risky proposition.

So what’s behind our frustration at people with BPD? What causes us to shift the blame from the disease to the individual? I think it’s a combination of time pressure and a psychological heuristic.

We can find clues to this psychological heuristic in other diseases that often frustrate clinicians. The aggressive patient with treatment-resistant schizophrenia who just bounces in and out of the psychiatric ward. The person with an (iatrogenic) opioid addiction whose whole life has been sacrificed to their doctor-shopping habit. The COPD patient who just won’t stop smoking. These are all chronic conditions that are difficult to treat, where one of the main symptoms or obstacles to improvement is behavioural. In these situations, we may stop attributing people’s behaviour to their disease and start attributing it to their character – which is very understandable, if their maladaptive behaviours never resolve and show us the person underneath.

The second factor behind our frustration at people with BPD is the pervasive problem of time pressure. These patients with difficult-to-treat diseases often take a lot of our time, so it becomes easy to resent them when we’re so time-poor. Moreover, busy schedules don’t let us stop and contemplate our own visceral reactions to patients, and question whether they’re fair. So instead, we take our emotional cues from our colleagues, or just accept our gut reactions as valid. This is a key step in practicing what you might call ‘back-foot medicine;’ doing a good-enough job, treating the acute problem in front of us and sending the patient on their way to make room for the next one. We forget to think about how and why we act in the ways that we do. We start to focus on ourselves and how busy we are, rather than the suffering of the patients and how we can help them.

This shift to back-foot medicine can be quite a subtle change, maybe even a subconscious one, but I suspect it happens far more often than we’d like to admit. It’s very understandable, given our circumstances, but at the same time could be quite pernicious, compromising patient care and weighing on our own subconscious minds.

So what’s the solution? How should we approach patients with BPD (or any other frustratingly maladaptive behaviours)? To answer that, I think we need to re-examine our often-inconsistent assumptions about the human mind. Do we have total control over our minds, or do we only have limited control over our thoughts and, in turn, our actions?

On the one hand, we seem to assume that people with BPD have total control over their minds and actions, and so we hold them accountable for their frustrating and destructive behaviour. But on the other hand, we seem to be letting ourselves off the hook by saying that we don’t have control over our own thoughts – ‘I can’t help it, they just rub me up the wrong way.’

We could try the opposite of what we do now: let BPD patients off the hook while criticising ourselves for any negative thoughts we may have. That approach might be more fair – after all, the patients are the vulnerable people here, not us.

But I think flipping the status quo like that and holding ourselves to such high standards probably wouldn’t be sustainable in the long run. Instead, what if we do exactly what we ask people with BPD to do in their psychotherapy: recognise that our cognitive patterns are unhealthy, forgive ourselves for them, then try to guide our thoughts in a healthier direction without letting them negatively influence our actions. The core of this idea is to not take our own mental problems out on others – which is often what’s so frustrating about the behaviour of patients with BPD.

I think this approach – noticing our initial reactions to patients and not letting them negatively influence our behaviour – could go beyond people with BPD, and could be applied in a lot of areas where we end up practising back-foot medicine. It doesn’t have to take long, and it doesn’t have to be a big deal. It could be as subtle a shift in attitude as shifting weight from one foot to the other, but it might make a world of difference for our patients and for the peace and satisfaction of our own minds.


Feature image by Rachel Collins at Flickr.

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