| There’s a saying
among medical professionals that everybody owes it to their colleagues
to take on a borderline or two. “Borderline” refers
to people with borderline personality disorder (BPD), who are
some of the most challenging patients there are—so challenging
the reasoning goes, that it’s only right that all practitioners
assume their fair share of these difficult people.
Borderline patients are hypochondriacs. They believe, almost without
ceasing, that something is dramatically wrong with them. And they
demand immediate relief of their enormous suffering, in the form
of medication, testing, referrals, or hospitalization. Substance
abuse—alcohol, prescription drugs or illegal substances—may
further complicate the picture.
Borderlines are relentless at getting what they want. So long
as you’re meeting enough of their needs, you’re a
hero. But make a misstep, which is just about inevitable amidst
the drama of their lives, and you’re a bum. This is called
splitting. People who suffer with BPD tend to view others without
shades of gray, as either wholly good or wholly bad.
I have started out, to every one of my borderline patients, as
a savior, as the doctor who finally really understands them and
their problems. Sooner or later, all but a few have thrown me
over because, in their eyes, I’ve failed them and because
they have found a new doctor who really, really does understand
them.
The stakes are high. Borderlines are subject to all sorts of self-harming
behavior, including substance abuse, self-mutilation and suicide.
So anything done to lessen their suffering can make a huge difference
in their lives and in the lives of the people who exist within
borderlines’ chaotic orbit.
There are numerous theories about the genesis of BPD, none of
which captures more than a fraction of the truth about this unhappy
way of existence. Some explanations say that BPD is merely an
extreme of the normal variation of personality. Others blame genetics,
abusive parenting, or toxic exposure early in life.
I’d like to discuss one theory of BPD that has special appeal
to me because it treads the line between science and spirit. The
ideas come from an article entitled, “The Role of Mindfulness
in Borderline Personality Disorder,” published in the October
2009 issue of The Journal of Nervous and Mental Disease.
The authors hypothesize that the extreme measures that borderlines
take to avoid being aware of uncomfortable emotions, sensations,
and situations precludes them from becoming habituated to these
experiences. “Habituation” refers to the lessening
of sensitivity that occurs with repeated exposure to a stimulus,
such as the sound of the train rumbling by to the people who reside
next to the tracks or the livestock smell to the feedlot’s
neighbors. By not allowing themselves to actually experience noxious
stimuli, whether internal or external, borderlines don’t
ever get to down-regulate their raw nerves. They find themselves
in a vicious cycle of escalating distress and attempts to avoid
it. Borderlines set the curve for dukkha, Sanskrit for suffering,
the theme of Buddha’s First Noble Truth.
For this study, the researchers enrolled 70 borderline inpatients
at a Dallas psychiatric unit, each having suffered extreme psychological
trauma in the past and severe impairment, such as major self-destructive
behavior, in the present. Participants were administered a number
of psychological tests, including the Mindful Attention Awareness
Scale (MAAS), a 15-item test which subjects rate, on a scale of
1 to 6. The MAAS assesses awareness of emotions, thoughts, actions
and situations. (A sample question, to be rated 1 to 6, is, “I
find it difficult to stay focused on what’s happening in
the present.”)
The study’s authors did find a strong negative correlation
between mindfulness and manifestations of BPD. That is, as mindfulness
went up, this particular form of suffering went down, and vice
versa.
Neither the researchers nor I would contend that lack of mindfulness
is the sole explanation for the dukkha of the borderline condition.
Still, mindfulness, a prescription for managing all forms of suffering,
might provide a handhold on the slippery slope of personality
disorder. Dialectical behavior therapy, a form of psychotherapy
used for some BPD patients, does include a component of mindfulness
training.
Over the years, a few borderlines have stayed in my practice for
a long time. The secret of our success has been to see each other
frequently, sick or not. That way the patient doesn’t have
to be in severe distress to gain my attention. At visits where
suffering is less, there may be enough attention and emotional
energy left over to build, gradually, a relationship that depends
on something other than the patient’s pains and the doctor’s
nostrums.
Occasionally we can develop enough mutual trust to move on, slowly,
to a healthier outlook and life. The relationship itself is therapeutic.
Developing a relationship with a borderline is no easy task. This
cluster of personality traits has no correlation with intelligence,
which means that a borderline patient may not only be needy, demanding
and manipulative, but plenty smart too. Borderlines provide me
with some of the greatest tests of my professional skill and personal
compassion.
Because I have a special interest in psychiatry and because there
is a huge need for compassionate care of these unfortunate individuals,
I have significantly more than my “fair share” of
borderlines in my family practice. How do I manage it? With mindfulness,
of course. Regular meditation practice is my most important tool
for managing difficult patients. By quieting my “monkey
mind” (or by allowing it to dwell with at least a shred
of ease in what causes me distress) I gain space between perception
and reaction when dealing with people who have black belts in
the art of pushing emotional buttons.
By no means am I ready to state that borderline personality disorder
is the opposite of mindfulness, nor that meditation is the cure.
Nevertheless, no matter what your relationship to BPD—patient,
family, friend, helping professional—I strongly recommend
that you try meditating. As my Great-Aunt Elke used to say (an
immigrant from the Ukraine, and a philosopher in her own right),
“It vouldn’t hoit.”
(See the Nexus
Interview on page 20 for more on meditation.)
Marc Ringel has spent the majority of
his career as a family doctor working in rural communities,
including the last 12 years in Brush, Colorado. He has
written extensively, for lay and professional audiences,
about rural health, medical informatics and healing.
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