I was sitting in the meeting room with a pen in my hand. The psychiatrist was at the helm, with the social worker and nurse manager on either side of me. The patient, a 30-year-old woman with a diagnosis of severe borderline personality disorder, sat across from all of us, bouncing her leg so hard that the table was shaking. I’ll call her *Jane.
This was my first admission meeting after I started working at this mental health facility. I was assigned as the primary nurse. And from what other nurses told me, *Jane was the most challenging patient with borderline personality disorder they’d ever had.
Borderline personality disorder causes emotional dysregulation resulting in symptoms ranging from unstable moods and relationship sabotage to extreme violence and suicidal behavior.
“Maybe you’ll bring a fresh perspective to this situation,” I was told by a senior nurse after she warned me not to get too close to *Jane.
During the meeting, I noticed the team spoke in a hushed voice and avoided eye contact. *Jane stared at all of us intensely. She had been in and out of the inpatient unit for over a decade and was well-known.
“Why do I have to keep repeating the same bullshit every time I come here, you should all know me by now?” *Jane barked.
“Yes, of course, but it’s the protocol to ask these…”
“Protocol my fucking ass hole!” retorted *Jane to the psychiatrist as he was explaining the admission meeting procedures.
The meeting was tense and uncomfortable. I’m not sure anyone got any helpful information. The questions were standard and mainly addressed the presenting issue that prompted admission.
I had read through * Jane’s history before the meeting and saw a long list of horrors that left me wondering if I was capable of handling this as a new nurse on the unit.
*Jane had lived on the streets most of her life, had been in the mental health system since her early teens, and was known to be violent to staff, herself, and other people. I was told that everyone else was burned out and didn’t want to work with her.
One thing in her profile caught my eye, “history of serious childhood abuse.” I had to flip back to her earlier admissions to find the details. All I saw was a note about how she was repeatedly physically and sexually abused as a child. Reading those words made my stomach churn.
In the days that followed, I was warned by several staff nurses never to turn my back on *Jane. Also, under no circumstances should I ask her any personal questions or answer any questions about myself. I was told to keep a distance, remain stoically professional, and don’t have any conversations with her.
One day, I forgot the advice about not turning my back on her. After bringing her morning medications, I turned to walk out of the room, and before I knew it, *Jane had me pinned against the wall with my ponytail in her hand.
Another staff nurse saw and called a code white, which promptly brought security. They were there in minutes, pulling Jane off of me, and putting her in a padded isolation room nearby.
I was deeply shaken, not just by the assault, but by * Jane’s horrifying screams and the violent way she was put into the room. Later that day, (and since I had already broken the rules) I decided to follow my instincts and talk to her about what happened. I brought a chair and talked to her through the clear thick door.
“What happened *Jane, why did you attack me?”
“Well, cuz I knew they’d put me in here.”
“But why do you want to be in here? You were kicking and screaming when they dragged you here?”
“I dunno, I like fighting with the security guards, and I like being here, it’s quiet and safe.”
We talked for almost an hour, and what I found out forever changed the way I look at mental health and borderline personality disorder.
Jane told me she was locked in her bedroom as a young child and repeatedly raped and beaten by her father. This went on for years before she was taken by child protective services and put into foster care. In almost every foster home she lived in, *Jane experienced further abuse.
Research shows that some victims of repeated abuse actually crave the same circumstances they grew up in because it’s familiar and, therefore, safe.
Also, extreme trauma is one of the biggest causes of borderline personality disorder. Yet, looking through her admission history, *Jane had never had proper trauma therapy. She referred to herself as a “lost cause,” and her extreme trigger responses made it difficult for her to receive help. In essence, she cycled between manipulative outbursts, where she sabotaged her therapy in a sad attempt to prove that no one loved her anyway.
When I approached the team about my discoveries, they laughed and called me a “newbie.” They reiterated that I shouldn’t have had in-depth conversations with *Jane as it would only make things worse.
I asked them why her admissions didn’t focus on trauma therapy. They said she was too far gone and could only be medicated to keep her and others safe. While I didn’t dispute that *Jane was a threat to herself and others, I couldn’t understand the blatant disregard for * Jane’s extreme trauma.
To this day, I can’t help but wonder if *Jane might have had a better quality of life if trauma therapy had been the main focus of her care since she was young and already in the system. When I asked whether she had early therapy, I was told that she couldn’t stick with treatment due to her violent outbursts. Yet, these outbursts were first documented later in her adulthood.
In the years that followed, I found the same story over and over. Many times, it was female patients who’d been raped and abused as children. Most of them hadn’t received adequate trauma therapy when they were still young.
Mental health practice and research all advocates for trauma-based therapy and there are counselors who provide specialized trauma therapy. Yet, why are there so many people who haven’t received this care in the mental health and child protection services?
And why was a patient’s trauma history not a priority for inpatient admission discussions and treatment coordination? It became apparent to me that we weren’t walking our talk in mental health services. And more so, my attempts to advocate were always silenced or ignored.
It’s interesting that research indicates that many mental health professionals get so triggered by personality disorders that they often avoid, dismiss, or undermine the patient’s needs. This is even worse if the patient is a woman.
It seems trauma triggers beget more trauma triggers, and most mental health care professionals don’t get support or proper training to handle this.
I’m not saying this was the only reason I left mental health nursing, but it was absolutely the beginning of the end for me.
Severe trauma can cause many alarming personality changes, with borderline personality disorder being one of the “disorders” that can manifest. But without proper early treatment, these issues escalate over the years and can erode any possibility for quality of life.
I hope with all the cries for better mental health care and improved social services, that we begin to make trauma a priority, especially for women. It’s also imperative that this begin early in childhood or teenage years. Research shows that even minor trauma can cause changes in the development of the nervous system. And while medication can help stabilize these changes, it doesn’t always work for everyone.
Also, experts admit that medication is one of the least effective avenues of treatment for borderline personality disorder. The first line of treatment should be rigorous and skilled therapy. Yet, medication was the only priority for borderline personality disorder during my inpatient mental health nursing career.
I began to wonder, was the medication really for * Jane’s wellbeing, or was it more about chemical restraint, or perhaps making her behavior more palatable for others?
It’s been many years since I left mental health nursing, and I certainly hope things have changed.