Iatrogenesis: How Health professionals hurt us
How did you feel when you were diagnosed with Borderline Personality Disorder? If you are like me you would have thought finally! There’s a name for this terrible suffering.
It’s good to be creative, but I’d clouded over the pain with so many metaphors — darkness, emptiness, soul-sickness, hell-on-earth, mental torture — I’d lost clarity. Sometimes words obfuscate to the point of incomprehension, and in my case led me further into the labyrinth of despair, (changing the paintwork of the bricks doesn’t knock down the walls). Now with the name BPD there may be a chance someone could help me. That’s what I thought at least.
Some of you may be angry with the diagnosis. After all you’ve just be officially told, your personality is the problem, which is like an attack on your whole identity. If so you feel upset you have every right to be.
The word Iatrogenesis is a useful one when it comes to the label Borderline Personality Disorder. It means damage ‘brought forth by the healer.’ Namely, symptoms which come about through the poor work of health professionals: The inaccurate labelling, the unwarrented medication, the dubious attempts at therapy. As British psychologist Peter Fonagy said in 2006, it is ‘harmful treatments’ that sometimes create the unrelenting crisis they want to fix.
I was diagnosed with BPD when I was twenty-one years old. However, the problems started in adolescent — emotional instability, interpersonal chaos, behavioural impulsivity, anger, depression, self harm, suicide attempts. Despite the obvious elephant in the room, nobody wanted to mention the illness which dare not speak its name. Perhaps the psychiatrists and psychologists misunderstood me. Maybe they misunderstood the diagnosis. Whatever the reason, I was given seven precursory diagnoses: Generalised Anxiety Disorder, Depression, Aspergers Syndrome, Non-verbal Learning Disorder, Obsessive-Compulsive Disorder, Emerging Schizoid Personality, Neurotic Personality. Obviously, I was a complex fellow, but if they asked me “whats wrong?” they may have found a better answer. That I was simply unhappy. It’s easier to give self-contained descriptions of an illness than analyse the context in which it occurs. In my case, I hated living at home, was struggling at school, and couldn’t cope with distress, and didn’t feel like anyone loved me.
How did all these diagnoses make me feel? Not very good is the short answer. I felt weak, stupid, fundamentally defective. The loneliness increased, so did the sense of disempowerment. The struggle went on. That’s iatrogenesis. When I became a human guinea pig and was stuffed full of various types of medication, I also didn’t feel very good either — physically. That’s also iatrogenesis.
In the psychotherapist-client relationship there’s always a power dynamic. You as the patient go cap in hand, to confess all your problems and the psychotherapist, pats you on the head and absolves you of your sins. If you’re lucky you may get some homework as penance to see you through the week, but often it’s just a case of “see you next time”. As I’ve got older, I’ve realised this label of BPD, (in fact all the labels), is misleading and damaging. Namely, being in the system, as a revolving door patient marked with a mental health condition, can be devestating to your self-esteem. With the professionals making snap judgements from medical records, and going off-script with therapy, long term recovery is jeopardised. Always be aware of what your going into.
The psychoanalysts couch
BPD lends itself quite well to psychoanalysis. After all it was the early psychoanalysts who first came up with the name Borderline, but also the first to posit a theory. Look up Adolph Stern, Robert Knight and Otto Kernberg and you’ll see how a diagnosis was invented. Most psychoanalysts (with the exception of Kernberg) believed BPD patients were on the border line between neurosis and psychosis, or more colloqually sanity and insanity. If a client was stubbornly resistant to analysis, then it wasn’t the fault of the therapist but the patient. And if someone couldn’t be analysed they were untreatable. Hence the old myth BPD is a dustbin diagnosis which people can’t get better from. Don’t let anyone ever tell you that, because recovery is real, and early psychoanalysts didn’t understand the condition, due to the impoverished outdated Freudian model of psychological injury.
Meanwhile, the prurient voyueristic eye of the psychoanalyst needs to be equally watched. According to the psychodynamic theory of BPD all symptoms, inevitably have some deeper meaning. They are the result, of introjection, projection, transference, libido drives, death drives, and warped objects relations. Psychoanalysts put the cart before the horse, seeking a unifying theory of everything before they offer treatment. As eminent scientist Karl Popper, claimed psychoanalysis a ‘pseudoscience’ because it setup to be irrefutable so it must be true — anything you say will be held against you. You’re angry not because the therapist is useless, but because you hate your mother. You’re not sad, because life is hard, but because your stuck in anal stage of development. Subjecting yourself to intense self-reflection is good — it helped me. But you don’t always need a psychoanalyst to do that, nor the theory. The psychoanalyst is just like you, only they have a degree, which means basic insights sound profound when wrapped in academia. There’s good evidence that Transference Focused Psychotherapy (Otto Kernberg, 1989) and Mentalisation Based Treatment (Peter Fonangy, 1999) work, however, the truth is that BPD is not some strange other-world state, but just a disorganised mind, that can be reordered with practise.
The CBT consulting room
You’re living in hell, burning with suffering; there’s an emptiness inside which can’t be filled. You’ve lost touch with who you are, what you want, where you’ve been and where you’re going. You see a CBT guru, and they promptly tell you it’ll be ok — if you challenge your negative thoughts with positive ones you’ll feel better. If you change your unskillful behaviour, to more positive behaviour you’ll be cured. Cognitive Behavioural Therapy is reductionistic and robs you of your story. How does it feel to see your rich personality turned into a simple deficit of skills, and a list of poor cognitions? It could make you feel weak, because despite best intentions the practise is just not working. In my case I was rather disgusted by such simple solutions. I knew intutiviely my story meant more than that. Of course BPD is complex even within the narrow confines of the scientific nomenclature; Dialectical Behaviour Therapy (Marsha Linehan, 1987) and Schema Therapy (Jeffrey Young, 1990) are two empirically sound cognitive-behavioural therapies which appear to work. Nevertheless they have limitations. To harness the truth of your own being you need to make this disorder mean something beyond a description. It has to be a story.
The Psychiatrist’s Ward
Pill pushers par excellence, psychiatrists consider themselves quite clever - having gone through medical school, attained multiple degrees, and acted as mental health policemen for so many years, they are puffed up on their own superiority. Of course, there are good ones about, but many are institutionalised to the point they see the label not the person. Nose in the textbook, they’ve forgotten the basis of relating to patients as people, not as problems. Even so, one thing psychiatrists should do in theory is tell you about the chemical problems in the brain which provoke mental illness. That as you have BPD your limbic system is overheating and like an unstaffed boiler set to blow. If he or she is generous they may remind you this isn’t your fault, but more likely a result of a genetic predisposition combined with a hostile environment in childhood. However, usually overworked and overburdened the modus operadi is a diagnosis and a pill. Unfortunately, there’s no drug for the personality, and while some evidence suggests that medication can target dysfunction — lamotrigine, carbamazepine, quetiapine — it’s mainly through numbing. Psychiatrists like John Gunderson and Mary Zanarini have introduced some science to the subject, measuring recovery, relapse, and treatment effectiveness, but reality doesn’t always fit the model. You also have a mind, of which you have more control over than you think. Seeing a bad psychiatrist is like being punched in the face. You go there looking for hope, come out feeling broken. However, you can be your own doctor.
The Emergency Room
Sometimes when life gets unbearable, the dormant death wish becomes active. We self-harm or attempt a para-suicidal behaviours and end up in hospital. We assume, having been taught it from childhood, that if there is an emergency, i.e. a mental health crisis, the emegency room is the best place to go for treatment. Unfortunately, it’s not true. Unless you want to be sectioned, or poked and prodded with medical instruments day and night. Here in the UK, even if your physically injured, unless your dying (and even then) you’ll be laid out in a trolley and generally ignored. As for patients with mental health problems, what chance do we have? I’ve experienced firsthand the hostility of health professionals, when they encounter the likes of us. Doctors, nurses, paramedics, all seem particularly resentful when it comes to patients with mental health. Of course here in the NHS, they’re overworked and underpaid, but still we don’t need to lionise a workforce when they are also quite ordinary. Some are good, some are bad, but in general, hospitals are lonely places, which invite iatrogenic damage. I’ve had cannullas shoved in my arm, till I’ve squirted blood, been made to lie on the floor because theirs no bed. I’ve even have a paramedic tell me to drink some medicine, only to find he’s given me a glass of vodka. It’s a disgrace, but of course they see us as as even more disgraceful. I suppose I went to A&E looking to be rescued, but in hospitals you’re more likely to be punished. They make you believe your unworthy of help but at the same time need it. The result is a vicious cycle, where you might keep going back. Get out now!
Be your own healer.
You may be wondering if all these professionals are iatrogenic destroyers, where to go for treatment. You may feel helpless or hopeless, wondering who can save you in the hour of need; in that crisis which takes you to the breaking point? You can help yourself. You can be your own healer. First be mindful of your emotions— Whatever you feel: Despair, rage, loneliness, distress, recognise it’s like this. Remember, that no one can rescue you from mind, body or situation. They can only point you in the right direction (and teach you a few tricks to help you cope.) Accept that suffering is part of life, and those of us with BPD have had more than our fair share, nevertheless, we have emotions because we are human beings. Remember treatment, works best with self-care, demonstrated through attentiveness and loving-kindness. That therapy can be a great learning curve, a way to train yourself but ultimately, you can do this alone. There’s no magic cure, no silver bullet, but you yourself can work out your own salvation. Remember all these labels, theories, pills and treatment plans are the superficial trappings of a greater mystery. The mystery of who you are. You are not inferior, nor superior, so no need to fall into the power dynamic which is so arbitrary it falls apart just as soon as the therapist looks at his watch. Be proud, forgive mistakes, be kind to yourself in light of limitations. Life may not be what you wanted, but you can make it a life worth living. Look at those iatrogenic wounds across the body, know that even if you can’t heal them, you won’t let yourself get needless hurt again.