Borderline Personality Week: when your desire to kill yourself is an annoyance to others

Jesus Christ I hate the wordpress post management system.  It published my first BPD entry three days early and then ate drafts of two planned posts.  Let’s see what I can recreate.

There are a lot of insights I get from working at the crisis chat center I would like to talk about, but talking about them requires examples, and using the chats as examples would be a huge violation of privacy, both morally and legally.  Lots of health care workers get around this by writing semi-fictionalized or composite characters, but I don’t feel skilled enough to pull that off.  Luckily, Kiera Van Gelder  wrote a book,The Buddha and the Borderline, about her recovery from learning to cope with Borderline Personality Disorder, and there is absolutely no privacy violation in using her as an example.

The first issue I want to discuss is how health care professionals treat BPDers’ threats of suicide.  Van Gelder was committed for short term stays due to suicidality several times- first as a young adult, and then three times in six months around age 30.   BPD can lead to suicide, at about the same rate depression, bipolar disorder, and schizophrenia do (with the exactly number being hard to determine because co-occurrence and misdiagnosis between BPD and the first two of those disorders is so common).  But BPDers are (perceived as) more likely to enjoy their stays.  That is probably because (crudely) depressed people want to kill themselves because they think everything is hopeless, bipolar people because they simultaneously think think everything is hopeless and have the energy to act on that belief, and schizophrenics think the CIA has told the demons where to find them.  Whereas BPDers are often thinking things like “no one cares about me.” and “I’m all alone.”  A hospital stay with kind staff checking to make sure you haven’t killed yourself salves this directly, and as such can be pleasant.  I can’t even judge them for this because even though I don’t think I’d have fun in a mental hospital, I got my IV nutrition + immune support at a concierge medicine place and it was awesome. *

But after two stays in a few months, the hospital was not so nice.  On the second visit, they told her that if she kept this up insurance would force her into the state hospital, which she would “not find so pleasant”.  When she came back a third time anyway they suggest maybe she needs to just learn to live with being suicidal and when she insists she is.  not.  safe.  they put her in a “rapid recovery unit”, which is basically a holding tank for the hospital to prove they did their due diligence vis a vis keeping her from killing herself while expending as few resources as possible.  It is not warm, it is not comforting, no one is demonstrating they care about her.

Perhaps the fear is that BPDers are faking suicidality, or worse, pushing themselves to become genuinely suicidal, to get attention.  I can’t prove that’s not happening.  And if anyone is going to do it, it’s probably borderlines.  But as I said above, the death-by-suicide rate for borderline personality disorder is only slightly lower than that for depression and bipolar disorder.   That doesn’t mean they have the same chance of following through on a given threat (it’s quite possible BPDers threaten more often), but it seems like the safer plan might be to give them more attention without requiring them to resort to suicide, rather than calling their bluff.

Perhaps it is that the act of denying a BPD sufferer admission to the hospital makes suicide more likely, in a way it doesn’t for other mental illnesses.  You might think that that would make admission a better idea, but a consistent thread in the medical treatment of BPDers is trying to make them get less out of treatment.  I’ll talk about that tomorrow.

[ An important note if you’re dealing with a person with BPD: even if they are making the suicide threat “for attention”, ignoring them doesn’t mean it will go away.  Suicide also looks like a viable means of getting attention and/or coping with not getting attention.  This does not obligate you to indulge their every whim when they mention the word suicide, you are in your rights to cut them off, but if you think the threat is credible, alert their support network or emergency services ]

*Have you ever had a nurse be happy to peel an orange for you?  I have.  Having insurance cover treatment at conceirge locations is like getting bumped to first class when you bought a coach ticket.