I Don't Want To Be A Good Mental Patient

| By Aafke van Pelt |

The one time I managed to render my therapist completely lost for words was when I told her I felt guilty asking anyone to be close with me, because it was “like handing someone a pile of exhausting diagnoses and telling them: ‘well, look, I never managed to love this, but perhaps you could give it a try?’”. My therapist looked genuinely sad. Perhaps a bit desperate. She was very sweet, my therapist. She really helped me. I felt a bit sorry for her. I cannot imagine I was a very good patient.

What makes a good or a bad patient? In researching doctor-patient relationships, Raul A. Borracci et al. observe that “regarding what physicians considered to be a good/bad patient, most common categories selected were the positive/negative personality traits and the adherence to doctor’s suggestions”. Bluntly: you have to be nice and do what the doctor says. I, however, was diagnosed with a severe personality disorder and it angered me – not because I did not like the diagnosis, which I definitely did not – but because it was right. What angered me even more was the treatment. I was never rude or intentionally recalcitrant. I always remained polite and tried to follow the therapists’ suggestions to my best ability. But from the moment I was diagnosed, I became my diagnosis. And I did not behave the way my therapists wanted someone ‘like that’ to behave, I was not grateful for this opportunity to better myself and I did not happily change everything about my life at their suggestion. I became a bad patient.

There is a subtle difference between having a disorder and being that disorder. Having it implies keeping it stored somewhere for safekeeping and the ability to give it away. Being it implies that it is an intrinsic part of who you are. Like an extra limb you just cannot seem to amputate, a hidden organ, perhaps somewhere at the top of the spine or near your heart where it is dangerous to operate. This view of being your condition is proven to inhibit treatment. As Aviram et al. state, “in many cases, people begin to blame the stigmatized individual for being the cause of the “discrediting characteristic,” changing the focus from the attribute (e.g., mental illness) to the person”. Unwanted behaviour, in other words, is not a result of a mental condition, but the manifestation of bad character. This view can extend to doctors and therapists.

I was not a person with a personality disorder. I was a personality disorder shaped like a person and everything I did was an expression of that. Aviram et al. also observe that this view often causes clinicians to believe that the patient has full control over their behaviour; what they do is an intentional choice and if it is a harmful one, it is malicious or manipulative. If I showed up to therapy tired, I had Developed A New Bad Pattern; the fact that I just had a bad night became an impossibility. If I felt happy, I was covering something up or maybe having a first ever manic episode. If I was distracted, I was disassociating as a coping mechanism, instead of briefly thinking about what I would have for dinner that night. It drove me insane. I was no longer a person with a mental health condition, I was that mental health condition with every fibre of my being.

We had group therapy. Eight members. Lovely people, all of them; hard workers, parents of children or pets, people with friends and hobbies and hopes and dreams. We had therapy twice a week, for half a day, and would have a short break during which we would all go outside to smoke or inhale secondary smoke. It came as no surprise to me that I picked up my smoking habit fairly quickly during those years. This was the only moment we would be together without our therapists, and we carefully voiced our feelings, our frustrations, nervously eyeing the windows as if our therapists would appear, hands pressed against the glass. We all agreed: therapy was difficult, but necessary. This was good for us (and it was). But we were also tired. We often felt, paradoxically, more reduced to the throes of our mental condition than before we started therapy, because our therapists, as explained above, treated us all as physical manifestations of our diagnosis. There was no room for nuance. Was this to be our life?

We would also all quickly mention that we were happy to be there, of course. That we were grateful for our therapy and that we could work on ourselves and help each other become more balanced, happy people. Who did not long for that little, approving nod from one of the therapists when you broke down and cried and managed to sob a string of dishevelled authentic thoughts? No matter that it rendered you a shaking wreck for the rest of the day, or, if you were unlucky, the week. Therapists loved it when we did that. I never really managed that level or emotional distress, which I often heard during my private sessions, the therapists were disappointed about. That I would actively choose to not cry – as if it was a choice.

Carla Chugani notes that people diagnosed with my disorder “are simultaneously viewed as if they are both out of control and as if they can control their behavior”. In other words, and I noticed this in the way my therapists approached me and the group, I did not have a grip on my emotions but I did that on purpose. This is paradoxical and, let us be honest, impossible. But what this resulted in, is that my therapists cornered each aspect of my behaviour. I became my diagnosis and everything I did was proof of that, or twisted to be that: a self-fulfilling prophecy. Any attempt to break away or find nuance was seen as deliberate difficult behaviour, bullying, manipulation, et cetera. Which was, of course, further proof of the severity of my condition. I could not be a rational person anymore or truly know my own thoughts I apparently wielded full control over. Not taking to some therapeutic practices well was considered a pointed choice, proof of my inability and unwillingness to truly change. Though I cannot possibly imagine a doctor blaming a patient with a physical condition for their body’s inability to process a type of medication!

Then the therapists told me that the first step is acceptance. I failed at that. All of them, the group therapists, the drama therapists, the ones who performed by EMDR therapy and the schema therapy, all of them, saw that as me making a deliberate choice to be difficult. Chugani observes that even licensed medical professionals often express frustration at having to treat people with my particular disorder, and treat them differently, less sympathetic, and are not often hopeful about the patient’s ability to change. Though my therapists were generally kind and friendly people who made more attempts to be patient than most people in my life, I did notice this prejudice in how they approached me and my fellow group members. Not getting me to accept my diagnosis means they failed at their job. Because I did not leave the therapy with high hopes and a pep in my step, the therapy was a failure.

I am aware I have not mentioned the diagnosis yet. There is still a large part of me that feels shame, and longs for the impossible day where I will wake up and it will be gone, like a distant nightmare that sometimes rears its ugly head and then leaves me shaken but balanced and happy. It is Borderline Personality Disorder, by the way. I do not particularly enjoy having it (or being it, if my therapists are right), I do not want it, and I resent that I need treatment, though I recognised its necessity and did it, gritting my teeth, sullenly. And, since Borracci et al. observe that doctors consider good patients to be compliant, willing and happy to do the work, I became a bad person whose example should not be followed. This, I feel, is a problem in mental health care – because now I feel like I am a failure for not accepting what I apparently chronically am and being a good mental patient. As if all of that effort and time and money was a waste.

By the way, I am aware that being diagnosed with BPD is not the same as having a physical chronic illness. There is nothing slowly shutting down my vital organs, or damaging my heart, or attacking my nerve system. In that sense, I should feel lucky. This will not kill me unless I let it. But it is lodged in me like a bullet in a lung. I do not have it. I am it, according to the world around me and the therapists who expelled their beleaguered sighs near me. And I have to spend the rest of my life handling it, preferably with grace and decorum and a brave little face.

Maybe if I am a really good, brave and exemplary patient, I could be a motivational speaker for other people dealing with BPD, to show you can have a fulfilling life. There are many such cases documented online and I am glad for those people, genuinely, I am glad they managed to develop such a tight and balanced grip on their diagnosis and want to inspire others to do the same. But I do not want to do that. I want my diagnosis and all it does to me gone. If you gave me a choice, I would get rid of it and pretend it never happened. The very thought of spending the rest of my life like this exhausts me. I will do it, do not get me wrong. I will even use the tools the therapists gave me because they frequently work. But it saddens and angers me.

Yet I often feel I am not allowed to feel angry at having this diagnosis. I received therapy. If I still experience difficulties, that is apparently because I’m not trying hard enough, because I am lazy, unwilling, reluctant, careless. But who in their right mind would willingly choose to keep their disorder and all its side effects? You cannot tell someone with BPD to just stop being so scared and sad all the time. You cannot tell someone with a broken leg to just stop having a broken leg and expect their bones to magically fuse back together. But once again, the diagnosis has become who I am, and my behaviour is proof of that. I am Borderline and any inability to handle that is a manifestation of bad character, not a logical result of severe mental strain. And I am not dying, am I? I will say it again: this will not kill me unless I let it. So, I had better not let it. Come on, you brave, good little mental patient!

If I do feel angry and resentful, I am damaging the entire community I am an unwilling part of, I am intentionally not doing myself any favours (could this be proof of self-destructive behaviour and the beginning of a new downward spiral? Discuss!), et cetera. But I am angry. I am diagnosed with one of the most stigmatised personality disorders there is, one that is proven to cause doctors and nurses to treat you with little sympathy and reluctance, one that rendered me a ‘complicated case’ which meant I had to wait more or less six years before I finally found a therapist willing to take me on, the disorder with the least sympathetic reactions from society, with a high suicide rate and a frightening selection of damaging side-effects. Would you not be angry?

The worst therapists are the ones that try to convince you to be grateful for your diagnosis, too, instead of just for your therapy. “Your diagnosis makes you who you are,” they tell you. “It makes you unique and creative and beautiful. You see the world in such a different way.” Those therapists make me want to punch the wall, over and over until my fist is a ragged stump, and then scrape the bloody, bony pulp off the wall and hand it to them and say, look, see, this is what I have to feel for the rest of my life, should I feel grateful for that? I just cannot imagine a doctor telling a patient with a chronic illness to be grateful for how it’s slowly eating away at their health. Additionally, many sweet and well-meaning people who tell me that my BPD has also added to my good qualities, would not want to have it if I offered. Because “research suggests people with personality disorders receive less public sympathy than people with any other mental illness,” Sheppard, Bizumic and Calear note. No one wants to be treated without sympathy or kindness. Telling me my BPD makes me more beautiful or interesting somehow is tone-deaf. If I could choose, I would not have it. I would give it away, amputate it and hope everything else, the trouble sleeping, the auditive hallucinations, the occasional inability to recognise my own face in the mirror, the problems with food, the soul-numbing bouts of depression, the social anxiety, the sickening dear of abandonment, the loneliness, the mood swings, the hours-long panic attacks, the body dysmorphia, vanishes with it. I cannot imagine anyone in their right mind choosing to keep it. Ergo: bad, bad patient.

I will say, me saying I do not want to be BPD does not mean I think all people with the same condition are bad and should feel the same way as me. I do not think that at all. They are fully-fledged people with intrinsic worth and as far as I am concerned, their diagnosis is a detail. Me saying I do not want BPD just means I would like my life to be easier. I would like to be easier. I would like to be an easy person. I am not. I cannot change that. I can just try to handle it. Failing at that makes me a bad patient. Failing to accept that makes me a bad patient. There’s no winning, really.

In the end, I think I’m just scared. Terrified because I know I have to keep a tight grip on it for the rest of my life, and what if I fail, what if it will take over and destroy the few good qualities I managed to cultivate and cherish? If I am honest, I would trade it all away, the positive things my BPD is apparently supposed to bring me. I would trade away my creativity, my ability to love big, loyally and deeply, my work ethic, everything, if it meant not having to get up every day knowing I have to work on myself. I am done working on myself. I am tired.

I think everyone with a personality disorder who feels frustration at their diagnosis and its correctness, should be allowed to feel and express that they would rather not have their disorder (if that is the case). It is not as harmful as you might think, in fact, it is honest. I think therapists should stop treating that expression as a proof of failure, of being deliberately difficult, of not wanting to be treated. Patients should not always have to be brave and grateful (therapy is not exactly fun or easy). Their diagnosis should not define them, not even to therapists. Just like any physical chronic illness does not define those suffering from it.

Therapy is a mourning process. You spend a lot of time mourning the person you could have been, the life you could have had, the ease you will never experience, the energy you will never be able to store. You mourn a version of yourself that is always imaginable but never achievable. BPD an exhausting personality disorder and it can be awful, I am going to feel sad and angry about having to handle it. But I will deal with it. I am not going to let it kill me.

Bibliography

Aviram, R. B., Brodsky, B. S., & Stanley, B. (2006). Borderline personality disorder, stigma, and treatment implications. Harvard review of psychiatry, 14, No.5.

Borracci, R. A., Gallesio, J. M. Á., Ciambrone, G., Matayoshi, C., Rossi, F., & Cabrera, S. (2020). What patients consider to be a ‘good’doctor, and what doctors consider to be a ‘good’patient: a text-mining algorithm-based analysis. Revista médica de Chile, 148, No.7.

Chugani, C. D. (2016). Recovered Voices: Experiences of Borderline Personality Disorder. The Qualitative Report, 21, No. 6.

Sheppard, H., Bizumic, B., & Calear, A. (2023). Prejudice toward people with borderline personality disorder: Application of the prejudice toward people with mental illness framework. International Journal of Social Psychiatry, 69, No.5.