Need Care? Be a Pain in the Neck

Over the past couple of weeks, I've been pretty fearful of losing my autism diagnosis now that the DID/PTSD was changed to BPD. I've had a number of arguments with various people over whether certain aspects of me, like my inability to live on y own or with little support, are due to autism or due to BPD. The answer matters in some way, because, as I said a couple of weeks ago, if it's BPD, it means it can be treated with cognitive therapy.

Now I have always been very adamant that my inability to live on my own is due to autistic organizing and processing difficulties. To the person believing the inability is due to BPD, this comes across as defensiveness: I'm just scared to take repsonsibility for my own life and I use autism as an excuse.

Unfortunately with this comes the idea that this fear will go away if I just get enough kicks in the butt. I know that flooding is used in anxiety treatment, but is it truly the most appropriate way of treating the fear of taking responsiiblity for your own life, assuming this is indeed what is going on?

I've often wondered and worried how people are going to tell that they are wrong in assuming that all my inabilities (except for those that are obviously due to blindness) are just insecurities. I mean, the only time I succesfully signaled that I needed more support, in 2007, I did so in a very much borderline way, ie. by threatening suicide in a public place. It is easy to say that this is my BPD acting up and I need to be ignored.

Of course, the currently mentally healthy person would say, why don't you just ask for more help in an appropriate way? Now I will tell you something about the way the care system works here: depression, anxiety or other emotinal problems are no grounds for care. Only behavioral problems are. In other words, if you need help, you've got to be a pain in the ass. Now please untangle this reality for me: if you're still well-behaved enough to signal you need help without destructive actions, you're obviously healthy enough not to need this help. Now if that isn't reinforcing behavior problems, I don't know what is.

Research Recommendations for Improving Treatment for People with Personality Disorders

Two studies in nursing journals that I read recently examine good practice for personality disorder treatment. Bowen (2013) specifically studied ideas for intervention with borderline personality disorder patients, whereas Fanaian, Lewis & Grenyer (2013) studied more general ideas for implementing personality disorder services. Bowen also emphasized direct intervention strategies, whereas Fanaian et al.'s study more focused on organizational structure. Bowen (2013) interviewed nine mental health professionals, four of whom were nurses, working at a specialist unit for patients with BPD. Key apsects of good practice mentioned by interviewees were:

• Shared decison making: for example, service users and staff should meet in community meetings to discuss and think through decisions that a service user might otherwise make impulsively. This thinking thorugh also counters black-and-white thinking.
• Rules should be actively recreated, rather than being strictly enforced or being abandoned. This is an offshoot from the shared decision making in the above bullet.
• Patients should have social roles, such as jobs on the unit nd group therapy with a pratical focus. This is a way of bringing into the open and then challenging interpersonal difficulties that are so typical of BPD.
• Social disturubances must not just be prevented, but also be used as an opportunity for learning.
• Peer support, including feedback on behaviors, but also including compassion. One interviewee also commented that peer support can enhance the patients' looking inward for the resources to help themselves, rather than viewing the staff as sole bearers of wisdom.
• Open communication. For example, this unit had a structure whereby three service users were elected to discuss issues happening on the unit with the staff as a means of liaison.
• Involvement with the person as a whole, seeing them as more than their BPD symptoms.

Bowen (2013) does highlight that not all of these aspects of good practice can be generalized. After all, this unit was a specialist unit for treating BPD and had its structure built so that these aspects of good practice could be met. For example, there were daily meetings, group therapy, and patients had jobs on the ward.

It was found that mental health workers on this unit had a pretty optimistic outlook on recovery from BPD. This is in contrast to research which shows that mental nurses have negative attitudes about BPD patients. Fanaian et al. (2013) emphasize this negative attitude towards people with personaltiy disorders as a major barrier to appropriate care.

Fanaian et al. (2013) had about 60 experienced clinicians in personality disorder treatment, including psychiatrists, psychologists, social workers, a nurse and a counselor sit in groups of four and brainstorm on topics relevant to personality disorder treamment. They overwhelmingly found that current practice in mainstream mental health settings is both poor and inaccurate. Ways to improve practice included:

• More education and training on the subject. Some groups also recommended that workers in non-psychiatric settings who have frequent contact with personality disorered people, such as social services staff, be trained in personality disorders. Carers, such as family and friends, also were said to need education and training.
• More support through supervision and leadership. For example, there should be more supportive and regular treatment team meetings. Clinicians also mentioned better access to Internet resources on treatmetn and assessment for mainstream mental health staff. There also should be greater support for staff approaching burn-out, as it was felt that staff working with personality disordered people have a high risk of burn-out and work-related stress.
• A shift from risk management to recovery-focused treatment and case management. Acute hospitalization should be avoided when possible. Rather, patients with personality disordeers need intensive, multidiscipinary case management.
• Clearer guidelines and protocols. Many groups of clinicians emphasized a consistent approach across teams, particularly when managing crises.
• An attitude shift to decrease stigma. Some groups emphasized the fact that many health professionals have a negative attitude about personalityy disorder patietns, and this is a barrier to effective treatment.

Fanaian et al.'s (2013) study, like all studies, has its limitations. The clinicians participating in the study were invited to a personality disorders meeting based on expertise and experience. Therefore, it is not known whether these findings generalize well into mainstream mental health provision.

References

Bowen M (2013), Borderline Personality Disorder: Clinicians' Accounts of Good Practice. Journal of Psychiatric and Mental Health nursing, 20(6):491-498. DOI: 10.1111/j.1365-2850.2012.01943.x

Fanaian M, Lewis KL, & Grenyer BFS (2013), Improving Services for People with Personality Disorders: Views of Experienced Clinicians. International Journal of Mental Health Nursing, 22(5):465-471. DOI: 10.1111/inm.12009.

BPD Subtypes

When searching for information on BPD, I came across a set of subtypes that describe the various features of BPD. These subtypes are:

• Discouraged: this type of borderline is either avoidant, believing no-one will like them anyway, or overly dependent on others. They have an intense fear of abandonment. Borderlines of this type may also suffer from depressive symptoms.
• Impulsive: this is the most hated BPD type among professionals. People who are primarily impulsive tend to act before thinkign. This includes violence or other antisocial behavior. Conversely, they may also engage in constant approval-seeking.
• Petulent: borderlines of this type use passive-aggressive behavior, including emotional or physical self-abuse, to get their needs met by others. They have an intense fear of abandonment,, unstable self-image, and inability to express their needs properly.
• Self-destructive: this includes depressive and self-harming tendencies. People of this type may not have many BPD traits other than self-injury and affective instability, so they may not technically meet the criteria of BPD.

Please note that people with BPD may have some features of one type and some of another. I, for one, have features of the discouraged and petulent types.

All types except for the petulent borderline operate in an abandoned child mode. Petulent borderlines operate in an angry child mode. I do see this point, but I want to stretch that the angry child usually masks the needs of the abandoned child, as my therapist explained. I myself cannot feel sadness unless I've first expressed intense anger or rage. Yesterday, I found myself in such a situation. I had had a minor conflict with my husband which led me to fear abandonment. As I got back to the ward, the nurses were assuming I'd had a good day - after all, it was my anniversary -, and were encouraging me to think positvely. Now I could and maybe will at one point write up a whole post on the positivity paradigm, but suffice it to say I snapped. I had a rage that, after a lot of back-and-forth screaming between me and the nurses, led to me running off and wandeirng around grounds screaming. I could only start to feel the sadness and fear of abandonment after I'd blown off some steam and calmed down again.