by Sean Erreger, LCSW, and April Foreman, Ph.D.
Yesterday, my client was admitted to the hospital for, I think, the eighth time. When will she understand she does not need to keep using the hospital? I almost welcome the break, because she is one of the most needy clients I have. She is being such a borderline, and her constant need for attention is exhausting. We keep reviewing the coping skills, but she keeps ER hopping and avoiding the real problem. She tells everyone she is suicidal, gets crisis responders worked up, and as soon as she gets admitted, she gets angry with people for sending her to the hospital. I think she is just manipulating things so she can move out of that housing program. She clearly does not want to get well.
—Hypothetical therapist treating someone with Borderline Personality Disorder
When Sean, one of the co-authors, wrote about the impact of language on suicide (with Jonathan Singer) for The New Social Worker, others began to discuss the power of language in describing other diagnoses and disabilities. The power of the language we use has clear implications for treatment. To paraphrase Dr. Oliver Sacks, the words we use influence our thinking (2009). The words we use to describe clients and others have impact, so choosing our words carefully is important.
Borderline Personality Disorder (BPD) is one of the least understood mental health diagnoses. The National Alliance for the Mentally Ill provides a fact sheet about BPD. It is a complex and often misunderstood diagnosis. It can be frustrating for clients and their families to manage the symptoms, which are mostly difficulties with mood regulation and often manifestations of self-harm. Further complicating this is a mental health system that is often not designed for people with BPD, despite its prevalence among people who present for mental health care (Gunderson, 2011).
This complex constellation of symptoms can be frustrating to clinicians, as well. Bourke and Greyner (2013) asked therapists open ended questions to describe their therapeutic relationships with clients with BPD and then compared those descriptions to those of clients with Major Depressive Disorder (MDD). Therapists expressed “greater emotional distress and an increased need for supportive supervision in their clinical work with patients with BPD.” They also noted that “clients with BPD were described as more hostile, narcissistic, non-compliant, anxious, and sexualized in their interpersonal responses than patients with MDD.” In their meta-analysis of research, Sasone and Sasone (2013) demonstrated that mental health clinicians harbor significant negative views about people who have BPD.
If we assume that clinicians are basically good people, who really want to help, why might they hold such attitudes toward people with BPD? How are they communicating about them with their language choices? How does clinician language about people with BPD interfere with care and recovery? And, finally, how can we change things and improve outcomes by changing how we speak?
When it comes to BPD, clinicians are often faced with a perfect storm of issues. First of all, clinicians are faced with patients who, by definition, have interpersonal behaviors that can be very painful. People with BPD might switch rapidly from being very complimentary and engaged in therapy, to displaying rejecting and painful relationship behaviors toward their therapists. Most clinicians, however, are not trained in how to care for people with BPD effectively, and they may feel surprised, frustrated, and angry with their patients and not know how to respond.
This can be further complicated by mental health systems that are usually not prepared to respond well to someone with frequent changes in mood, behavior dyscontrol, and constantly changing suicidal ideation and crisis. Without proper training and support, clinicians and community treatment teams begin to feel hopeless toward people with BPD, and they often take a passive-aggressive stance toward such clients in response.
Let’s examine some of the language and how it perpetuates negative associations.
1. “She does not need to keep using the hospital….” This may be true, but the underlying implication in our hypothetical therapist’s narrative is that the person with BPD is somehow to blame for frequent hospital use. The truth is that patients cannot “fail” at treatment. Frequent hospital use is often a sign of poor coping skills, behavior dyscontrol, and treatment failure. It is powerful and important to acknowledge that a therapist can fail a patient and that a treatment can fail a patient, but a person cannot “fail” as a patient. If someone with BPD is overutilizing hospital visits and not recovering, we should change our language to reflect that something within the system could be failing the patient.
2. “Being a Borderline.” This label does not inform a clinician as to what to do; it simply states the diagnostic term, which has little to do with how one should treat the individual. This statement also ignores the fact that people with BPD can and do recover when given effective treatment. Well over 50% of people with BPD are significantly better and stay better after receiving dialectical behavioral therapy and other effective treatments (Linehan, Dimoff, Koerner, & Miga, 2014; DeVylder, 2011). People with BPD do not have to have it for life. It is not something they “are.” It is a highly treatable diagnosis they have.
3. Being “Needy,” “Attention Seeking,” and “Manipulative.” This is a matter of perception. Again, there is a need to look at what is happening from the client's perspective. All of us have needs. We can all be “needy” when those needs are not being met. People with BPD often have large scale, unmet needs, often the result of traumatic, abusive, and chaotic environments. They often have unmet therapeutic needs, as well, often attributable to not receiving effective, evidence-based treatment. All of us need “attention.” People with BPD may have real problems that elevate the amount of attention they need. They may have poor skills that cause people to withhold attention or give them painful attention. Finally, “manipulative” is the term most misused in this case. All of us, from birth, manipulate the environment to get our needs met. Usually, people with BPD behave in ways that encourage people in their environment to withhold things from them and mistreat them (and often they are in abusive environments to begin with—that’s how they got BPD in the first place). They are often the opposite of manipulative, as they are usually impaired at getting their environments to respond to them.
4. “She clearly does not want to get well.” People with BPD have intense emotional pain—so much so that 3-10% of people with this disorder die by suicide (Gunderson, 2011). Nearly everyone wants to recover. When a patient with any other kind of severe and possibly terminal diagnosis gets worse, we do not blame them. We look for better treatments and feel sympathy. This kind of language blames a person for the disorder and lack of recovery, and simultaneously shifts the “blame” away from treatment and system failure. It shifts power and responsibility for treatment away from the clinician.
So, why might many clinicians, who are basically good people, say such things? The truth is that the therapy skills for helping people with Borderline Personality Disorder are often not taught in schools and training programs. Most treatment settings (both inpatient and outpatient) have a significant population of people with BPD, without having access to trained therapists or enough treatment access available to meet the intense, and frequent (but temporary), therapy needs of someone with BPD. Because of regular treatment and system failures, many treatment teams and clinicians feel helpless about caring for people with BPD. It would be natural to shift the blame to patients when someone feels overwhelmed and unsupported in caring for them.
Let’s attempt to rewrite the narrative. Let’s think about how to change this rant to reflect person-centered language and solutions.
Yesterday, my client was admitted to the hospital for, I think, the eighth time. It’s clear from reviewing her charts that our treatment plan is not working. I wonder if she is going to the hospital so often because we aren’t set up to provide the coaching and support she needs. I know not having enough resources for her in our clinic is driving her hospitalizations up and burning me out at the same time. The real problem may be that this treatment plan is not effective, and we have to do something else that actually works. This treatment failure is burning out everyone in our community, and setting her up to go into crisis. If we don’t change things, everyone at the ER and on her treatment team will start feeling so frustrated and hopeless they might take it out on her. I know she wants to get well, but there are also conflicting issues with her housing and lots of other things in her environment that are reinforcing poor coping and staying in crisis. Maybe I need to consult with a team about her treatment and make some changes.
Changing the narrative in cases like this may make the difference between a lifetime of unnecessary suffering and giving someone a life worth living. In the first narrative, we need to ask, does this really convey what I think about this client? More importantly, does it guide our clinical thinking? Language in the first narrative leaves little room for a clinical formulation. The first narrative is full of hopelessness, powerlessness, and frustration. Changing the narrative opens up possibilities and hope for both the client and the clinician.
The language we use to describe individuals has power (for both our clients and ourselves). When communicating with other professionals, we should be mindful of how our language communicates our thoughts.
It is important to remember that individuals require effective treatment and treatment with dignity. It is important to assess your and the organization’s confidence to treat individuals with borderline personality disorder in a respectful manner. Do you feel confident to change the narrative and provide good care? If not, what changes should you make? Does your system respond effectively to the needs of people with BPD? If not, how can you advocate for changes that will improve their odds of recovery?
Without person-centered language and good resources, we often lose sight of our goals. Helping individuals through emotional distress can be difficult. We have to believe all individuals are capable of change, and our language and actions need to reflect this.
Bourke, M. E., & Grenyer, B. F. (2013). Therapists’ accounts of psychotherapy process associated with treating patients with borderline personality disorder. Journal of personality disorders, 27(6), 735-745.
DeVylder, J. E (2010). Dialectical behavior therapy for the treatment of borderline personality disorder: An evaluation of the evidence. International Journal of Psychosocial Rehabilitation, 15(1) 61-70.
Gunderson, J. G. (2011). A BPD brief: An introduction to borderline personality disorder: Diagnosis, origins, course, and treatment (Online Article). Retrieved from http://www.borderlinepersonalitydisorder.com/wp-content/uploads/2011/07/A_BPD_Brief_REV2011.pdf
Linehan, M. M., Dimeff, L., Koerner, K., & Miga, E. M. (2014). Research dialectical behavioral therapy: Summary of data to date. Chart online. Retrieved from http://behavioraltech.org/downloads/Research-on-DBT_Summary-of-Data-to-Date.pdf
National Alliance for the Mentally Ill. (October 25, 2015). Borderline personality disorder. Retrieved from https://www.nami.org/Learn-More/Mental-Health-Conditions/Borderline-Personality-Disorder
Sacks, O. (2009). Seeing voices: A journey into the world of the deaf. London, England: Pan Macmillan.
Sansone, R. A., & Sansone, L. A. (2013). Responses of mental health clinicians to patients with borderline personality disorder. Innovations in Clinical Neuroscience, 10(5-6), 39–43.
Sean Erreger is a mental health case manager for youth in Upstate, NY. He blogs about social work, mental health and healthcare at http://stuckonsocialwork.wordpress.com. He is also a co-moderator for the Suicide Prevention on Social Media tweet chat (#spsm).
April Foreman, Ph.D., is a licensed psychologist serving veterans as a suicide prevention coordinator for Veterans Affairs. She is passionate about innovative and effective care for people with severe emotional pain, and especially advocates for people with Borderline Personality Disorder. She is the co-producer of the Suicide Prevention Social Media (#SPSM) chat.