Psychiatry was my first clinical rotation, and I did not know what to expect when I began. When I initially got assigned to the dialectal behavioral therapy (DBT) team, I had no clue what that would entail beyond working with some borderline patients and that the preconception of borderline patients is that they can be “the most difficult” patients to help due to their intense emotional instability, chronic feelings of worthlessness, self-destructive behaviors, and unstable relationships. While sitting at rounds each morning, I found that our clients unpredictably struggled and triumphed with different matters day in and day out. I heard stories about how dysfunctional they can be, but I also witnessed how ordinarily functional they are.
When I worked in the emergency department, I was always surprised to hear psychiatry and non-psychiatry residents alike throw around the sentiment, “That was a classic borderline patient!” whenever they had a difficult encounter with a patient. Because I worked with true borderline patients, I knew that you could not definitively diagnose any patient with any personality disorder based on one clinical encounter.
This is especially the case I would think when people are coming into the emergency department suffering from an acute crisis. I do not believe that many people, even the most functional, are at their best when they suddenly find themselves lying on a hospital bed, surrounded by unfamiliar lights, noises, and people, while also dealing with fear, anxiety, helplessness, and pain. It is a bit disheartening when people suddenly classify difficult patients as “borderline” as if that’s the only defining feature of what it is meant to have a borderline personality disorder. When I worked with borderline patients, I came to understand that you can be a borderline patient and also be a non-difficult person and that their problematic phases were only one aspect of their lives.
It can be easy to think when you only classify your thoughts as either “black” or “white” and patients as either “good” or “bad.” This is often how people with borderline personality disorder usually think, but I also feel that this is the kind of troubled thinking that physicians can fall into the trap of when they dismiss their patients as difficult. When running DBT sessions, we stressed that there can be multiple and opposing truths that exist at the same time. As a student working at the center, I learned that it was critical to approach each day with a new optimism and curiosity that was not colored by the past, which was particularly important in helping our borderline patients strive for improvement, especially on days after our patients had regressed by abusing drugs, cutting themselves, or getting into physical altercations. If you had resigned your patients as failures, then it would only be more difficult to begin to have high hopes and expectations for them while also helping them improve and reach new goals.
Throughout my psychiatry rotation, I continued to learn many more important lessons, one of which was that I realized that one of the crucial components of an individual’s character and resiliency is their social background. For one of my patients, Mr. G, this was no exception. He grew up in a difficult situation with parents who divorced, a father who turned to alcohol as his coping strategy, a mother who frequently arrived at the hospital for inpatient psychiatric admissions, and an older brother who has thought committing suicide was the best option when times became difficult. When these are the behaviors that the closest people around you are utilizing to handle life’s struggles, it is not difficult for anyone to understand that someone growing up in these conditions may think that they have limited options to turn to when they confront their own stressors. I valued engaging these patients in DBT training because the strategies being taught were not solely for someone with poor coping skills but were fundamental guidelines that would be universally helpful to anyone.
The social history is a critical part of understanding a patient, but it is often left until the end of a medical encounter. Without it, a doctor may still be able to diagnose a patient’s illness, but only with it can a doctor really appreciate the highs and lows of how a patient is managing and living with their diagnosis. With Mr. G’s high HbA1c levels and lack of endogenous insulin levels, any doctor could diagnose him with type 1 diabetes but one cannot begin to appreciate the complexity of his diabetes care without also knowing that he is homeless, unemployed, and estranged from the mother of his daughter all in the setting of an unmanaged mental illness. Nor can they understand the acuteness of it when his father unexpectedly and suddenly passes away on top of everything else.
Patients provide doctors with the privilege to learn about their most intimate and personal information. Without asking, doctors lose out on essential pieces of data that can help guide treatment. I learned many important lessons during this past month on psychiatry; one of which was on the intricate and symbiotic relationship of our biology and our social environment. Furthermore, I also appreciated every day that borderline patients who are “the most difficult patients” can also be the most rewarding patients.
Michael Nguyen is a medical student.
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