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By Sonia Neale

emergency240People with a diagnosis of BPD are often accused of manipulation and splitting in psychiatric settings.  A quick Google search reveals that manipulation is the action of manipulating someone in a clever or unscrupulous way, the skilful handling, controlling or using of something or someone, to manage or influence skilfully, especially in an unfair manner, to manipulate people’s feelings. I have never felt skilful, clever, influential or in control in an emergency department or hospital setting yet I have been accused of manipulation and splitting.

What I do feel is shame, shame, shame and more shame, along with confusion and fear.  I feel physically sick and unsafe.  My body is burning internally.  Shame causes the amygdala in our brain to produce a cocktail of poisonous chemicals.  We are burning from the inside out.  Invalidating our feelings is like throwing petrol onto an already fierce raging fire.

Imagine a grizzly bear bounding into emergency and bailing you up against a wall and someone in charge expects, no demands, that you sing “The Star-Spangled Banner.”  How many of you would be able to do that with adrenaline and cortisol screaming around your brain and body?

When my amygdala is in charge of my body, and my pre-frontal cortex is in hiding, I am operating on fright/flight and freeze.  I am falling down a deep, black bottomless pit.  When I am well, I can manipulate, that is, I can plan ahead in a clever and skilful manner and I am in control.  My brain is cold and analytical.  People with antisocial personality disorders have cold amygdala which is why they can con people out of their life savings.  People with BPD have boiling hot amygdala and would find writing their name a challenge.

When we are in the middle of a BPD amygdala meltdown we regress to a very young age and swearing is part of this regressed condition.  We use primitive forbidden language as nouns, verbs and adjectives because we do not know how to cleverly and skilfully manipulate language to get our emotional needs met.  At this point we are almost pre-verbal.  Swearing can help expel the feeling that we are burning up inside.  It dampens and discharges the toxic chemicals.  It feels cathartic.  I feel for the person receiving this torrent of cathartic emotions.  I have been on the receiving end of this a few times.  I feel for the emergency and psychiatric staff.  This is part of the devaluation process consistent with the nine BPD symptoms; please separate the person from the behaviour.  Effective training helps people understand why this happens.  Please do not take this devaluation, regression and lack of language skills personally.

A BPD meltdown with all its colourful language in the moment is a life-threatening experience for us.  Let me repeat that.  We are experiencing an out of body, near death experience.  We are paranoid and dissociated, also criterion for a BPD diagnosis.  Again please do not be surprised when we walk through that door displaying all nine symptoms in the moment.  We are doing what we are supposed to do, according to the DSM V.

The DSM V was written for a reason, it is the psychiatrist’s bible, and one that is always referred to.  The DSM V clearly states the idealisation/devaluation process as part of the nine symptom range, so why do hospital staff show disgust and revulsion when we assign you as good or bad?

An extremely clever group of professors got their pre-frontal cortexes together and created the nine symptoms from people’s observable behaviour which ironically is sometimes used as exclusion criteria for admission to a hospital.  Go figure!

On the other hand, I know of people with BPD who go to emergency or have a hospital stay and are very, no overly, compliant, agree with everything and everyone and still get accused of manipulation and splitting.  This is me; I have never had a violent outburst in a hospital situation.   I have however had many a meltdown at home on many occasions and once at a shopping centre car-park.  Sometimes, hospital staff have preconceived ideas based on other people diagnosed with BPD who have presented at emergency departments.  Please treat each person as separate and unique.

People with BPD are also accused of “splitting” teams in psychiatric settings.  Again idealisation and devaluation are part of the symptom criteria, so again why is anyone amazed at this?  The idea is to have a very strong, very cohesive, transparent team, where everything is laid on the table in front of everyone else at regular staff meetings.  Have plenty of staff supervision and if necessary counselling appointments available.  How well is your team trained?  Have they ever had a person with a recovered lived experience of BPD come and talk to them about what it feels like to have BPD?  Do you have a peer support worker with a recovered lived experience on your hospital based team?  We all need to work together in this.  I have been a BPD patient and now I work in a mental health setting where I can be devalued by a person with BPD.  I know from both sides of the fence what it feels like.

People with BPD have deep seated relationship issues and communication breakdowns.  Do not expect us to operate in LogicLand, expect us to have relationship issues with you as again this is a symptom clearly stated in the DSM V.  It is your job to get training and think outside the square.  Change the way you communicate with us.  We feel toxic shame for being who we are.  Validate us just for doing the best we can with what we have.  Validate us unconditionally just for staying alive.  We don’t get our emotional needs met in emergency departments because you are not trained in BPD language.  We unconsciously recreate our dramas in psychiatric settings.  We replay our dysfunctional relationships in therapy.  When we are exited from emergency departments, sewn or patched up, we are sent home by ourselves without referral or resources or we are referred to BPD therapy services that do not exist.

Thank goodness in New South Wales in Australia we have Project Air Strategy, a university based research centre who are rolling out an education based programme for emergency department staff.  Finally an Australian state government is prepared to put money into people diagnosed with Borderline Personality Disorder.  I feel there are some very clever manipulative people out there with most amazing pre-frontal cortexes who have enough skill, control and influence to convince others in charge of the country’s purse strings that we are worthwhile human beings.


Emergency room sign photo available from Shutterstock

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