As someone who once suffered world-class symptoms of borderline personality disorder that resulted in multiple admissions to hospitals, but who has since gone on to rejoin society, I can offer some perspectives on this disorder.
The first misconception most people have about borderline personality disorder is that its dramatic manifestations such as reckless or suicidal behavior are merely deliberate, manipulative attempts to get attention. That is not true. The distress is real.
For me, when I was acutely ill, no other options besides my suicidal behavior existed. I often fervently hoped each overdose would be the last or that finally someone would "see" how much help I needed. I had complete tunnel vision and couldn't envision yesterday or tomorrow. While having my stomach pumped in an emergency room or while running away from a psychiatric hospital, I would careen from high to low in euphoric bursts; I felt as if I was watching someone else. Even if the experience was unpleasant, which it usually was, I was unable to learn from it. Brief moments bordering on lucidity were too painful. It was as if part of me was asleep and I couldn't wake myself up, or was too afraid or felt too hopeless to wake myself up.
I was accused of intentionally reacting in certain ways and was once asked sarcastically by a doctor, "Is this enough attention for you?" But inside I was more like a frightened two-year-old than the cunning individual he thought I was. I couldn't see what I was doing. Mostly I felt desperate, with a longing to be permanently looked after, and I felt addicted to looking for help. I can explain these feelings only on reflection.
Some people believe people with borderline personality disorder "enjoy" it and don't want to get well. Wrong. I was out of control and couldn't have changed my behavior if I wanted to because I was looking for rescue. But each time the response from health care providers would be different. I felt, in a warped way, that their concern did clarify my existence, but my panic, fear, and anger took over when my racing thoughts and attempts to flee were stopped.
When I would overdose and when medical intervention, usually by force, was deemed necessary, I would feel temporarily hopeful, and then threatened, judged, and thwarted in meeting some sort of need. Oh, how I see the futility of it now. I was incapable of seeing it then, and I secretly wanted to be respected, liked, and approved of, but I didn't know how to attain these privileges or whether I was worthy of them in the first place.
The best way I have heard borderline personality disorder described is having been born without an emotional skin—with no barrier to ward off real or perceived emotional assaults. What might have been a trivial slight to others was for me an emotional catastrophe, and what would be a headache in emotional terms for someone else was a brain tumor for me. This reaction was spontaneous and not something I chose.
In the same way, the rage that is often one of the hallmarks of borderline personality disorder, and that seems way out of proportion to what is going on, is not just a "temper tantrum" or a "demand for attention." For me, it was a reaction to being overwhelmed by present pain that reminded me of the past. To put it simply, think of something that would really hurt you and multiply it by a hundred.
If several stressors occurred in sequence, I sometimes started to generalize, negatively. The past and the present became one. Feelings swept over me like one of those nets used to trap animals in the jungle—black, dark, persistent, and at times suicidal feelings. Those feelings, accompanied by flawed logic, fantasies of rescue, and a kind of self-preservation system gone awry created chaos in my mind. I would feel hopeless, my world would compartmentalize, and I'd enter an unremitting state of shock. The pain would seem interminable.
Thus the pain experienced by people with borderline personality disorder is not just a result of simple immaturity, a brilliant imagination, or the longings of a so-called spoiled child. We don't end up certified, in police lockups waiting to see a psychiatrist, or even dead because we're morally deficient. Our pain is real, but the equation creating that pain is faulty. Something is shut down in our brains that means we can't listen at first because we're in survival mode.
My longing for rescue made me, especially after I entered the treatment system, run, flee, turn to authorities for help, be chased. In fact, I fled from security (that is, I left the psychiatric unit), running away but still wanting to be caught, to be contained but not suffocated—primal feelings that I couldn't verbalize then. To say it was an altered state of consciousness is putting it mildly. All I can say now is that there was something I wanted to be gone but at the same time didn't wish to lose.
The most important thing is, Do not hospitalize a person with borderline personality disorder for any more than 48 hours. My self-destructive episodes—one leading right into another—came out only after my first and subsequent hospital admissions, after I learned the system was usually obligated to respond. Nothing that had happened to me before being admitted to a psychiatric unit for the first time could even approach the severity of the episodes that followed.
What I did after I entered the system was to survive using maladaptive tools as a result of knowledge I acquired in the hospital. The least amount of ill-placed reinforcement kept me going. It prevented me from having to make a choice to get well or even finding out that I wasn't as helpless as I believed myself to be.
In the community, a person with borderline personality disorder can discover how to live. Hospitalization activates needy feelings and perpetuates the patient's sick self-image in her own eyes and those of staff. I believe if you live with the lame, you learn to limp. I know I did. Hospitalization is too easy an "out," but episodes of self-harm may very well reduce or disappear if the patient knows the response will be minimal.
A person with borderline personality disorder is often just looking for reassurance rather than admission when she hints at or threatens suicide—she doesn't yet know how to directly and safely express her feelings. If she is admitted, however, she will probably regret it five minutes after she gets in. Without hospitalization, she can see that what seems beyond endurance usually is not. This realization has allowed me, albeit slowly, to grow and learn to cope. Tolerating pain and uncertainty is the only way this can happen.
The person with borderline personality disorder doesn't know how to wait, and a system that immediately responds doesn't give her a chance to soothe herself. Therefore, she continues to believe she is helpless. A man in an emergency room once said I would have to grow up and take care of myself. Reflecting the helplessness that I felt, I screamed at him, "I can't! . . . Don't you know that alone I'm going to die?" It was flawed but to me believable logic, with emotions literally blocking the intellect.
When you as a service provider do not give the expected response to these threats, you'll be accused of not caring. But what you are really doing is being cruel to be kind. When my doctor wouldn't hospitalize me, I accused him of not caring if I lived or died. He replied, referring to a cycle of repeated hospitalizations, "That's not life." And he was 100 percent right!
I would never have the life I have today if I had continued to get the intermittent reinforcement of hospitalization. The longer I stayed out of the hospital, the less I wanted to be in. The devastation I would have felt at supposedly losing my foundation of recovery would have been far worse than what I was feeling at the time. When I started to struggle to put my life together, sometimes all I had was that ever-growing time out of the hospital—which, with the exception of a short stay during the summer of 1997, has spanned five years—as something positive I could point to.
A word of advice to mental health professionals that cannot be stressed too strongly: don't define people with borderline personality disorder too strictly by any textbook limitations you have read. I have exceeded my doctor's expectations for improvement, and he doesn't know how far I can progress. For the most part I've stayed out of the hospital, maintain long-term full-time employment, live independently, have a motor vehicle, and plan to pursue further educational opportunities. If I—as one of the most chronic, regular, well-known, persistent visitors to emergency rooms in my community between the late 1980s and early 1990s, and as one of the most chronic hospital escapees, and as someone who was written off and told so—could triumph over borderline personality disorder to this extent, I'm sure other people with the disorder can at least improve the quality of their lives.
Someone answering to my name was once a terrified, angry person who was showing up in emergency rooms nearly every night and throwing up into a basin, or was being looked for regularly by the police when threatening suicide. Someone answering to my name also once fought nasogastric tubes and ran from nurses, doctors, police, and hospital security. But that wasn't the real me. That's not who I want to be.
Nor are the other people who are seen through the pathology of borderline personality disorder showing their real selves. As frustrating as these acutely ill people may be, please don't write them off. Maybe, just maybe, you'll be able to help one of them. I'm living proof that—over time—we can be helped.
Ms. Williams lives in eastern Canada and works full time in the legal system. She has written a resource manual and has made speeches to mental health professionals about her diagnosis. Send correspondence to her in care of Psychiatric Services, 1400 K Street, N.W., Washington, D.C. 20005. Jeffrey L. Geller, M.D., M.P.H., is editor of this column.