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.