Borderline Personality Disorder: should we challenge the diagnosis or just accept the institutional prejudice?

After several years of debating with J about the futility of challenging a diagnosis, I'm suddenly acutely aware of a need for change. There's some very negative and consistent aspects to her treatment and attitude from professionals which make me more or more certain that she is has been not only a victim of prejudice against patients with Borderline Personality Disorder, but also there's a theme to the ongoing failure to adequately risk assess and safeguard J when she is suicidal. Basically they think she is "acting out", bluffing or faking. It's as though, to the MH professionals, her suicidal feelings are in fact "ambivalent" (recent quote from junior doctor) and that she will not follow her thoughts through.  In her current care plan we had asked the nurses to help J with aspects of her illness which we have identified, for example: depression, low mood, help with low self esteem, an allowance for discussions about OCD, and keeping an eating disorder in check. A positive recent development has been the nurses on her ward putting her in contact with a place that helps rape victims (before I was with her she suffered two awful separate rapes and despite all the contact with consultants over the years, to my knowledge, has never been offered therapy for this).  The doctors are often not interested in J's adult life experiences (which may have even manifested as PTSD) and often only refer to her childhood. Again, this is part of how doctors approach BPD, by talking about the emotionally stunting which can occur in childhood which can result in a perpetual adolescence where the patient refuses to act like an adult. I.e. they want the patient to grow up and take control or responsibility.  Naturally this is supposed to be up to the patient to magic out of nowhere, whilst they are treated with indifference by staff, for fear that any acknowledgement will condone and validate the patient's current views and behaviours.  So when the patient says, "I hurt, I want to die. I will kill myself."  they will be treated as though they are making a threat, that they are emotionally blackmailling family, friends and professionals, and so the response is non-negotiable "tough love".  The professional will set "boundaries" to the care, compensating for the patient's lack of rules (or support) in childhood.  Reading around the subject of risk management on mental health wards it becomes very apparent that nurses and doctors routinely underestimate the risk that PD sufferers pose to themselves.  This is contrary to what I would have expected, since studies between the relationship between self-harm and suicide always places the the self-harmers in a higher risk.  Again prejudice about self harm is closely tied in with prejudice about BPD, i.e. that self harm is part of attention-seeking behaviour.  Many patients self harm for different reasons, and in my experience the professional response has always less to do with training and more to do with the experiences, personality and compassion of the staff treating the patient.   I have recently read that self-harmers may no longer have the "body barrier" - innate self-preservation is lessened, and the method is no longer feared (cutting, ligaturing, dangerous environments).  I'm guessing that if you self harm, it's just seen as an attention seeking sympton of BPD, and perhaps not even recognised as a coping strategy or even a way of preserving one's own life (ironically, bearing in mind what I've just typed).  Locally (in NHS community and hospital teams, not without referral to outside agencies) I've never heard of self injury being treated directly/therapeutically.  Maybe it's like random shouting, it's just seen as one of those things which will subside when the patient's main diagnosis is being treated, not even seen as a complication, just a compulsive action.  Illegal drug use and drinking get more recognition than cutting or burning, certainly they are more normalised.

Even if J has BPD, her suicidal thoughts and plans will never be taken seriously, her self harm and eating disorder will always be viewed as part of a package of anti-social belligerence, going back in time to bad birthday, perhaps.  This is probably the reason why when we, carer and sufferer, contact professionals, when she is distressed, it's only after going to A&E and surviving an overdose or being physically marched into hospital by police will J be admitted to hospital.  Up to that point it's all the cliches about cups of tea, taking meds, distracting self, and wait to talk to the CPN (if you are lucky to have a CPN, they will almost certainly say all the same things and not recommend an assessment or ward stay, in fact, sometimes they will claim it's not it there power to initiate these things).  
In J's case, policemen, nurses and paramedics seem to warm to J and even sympathise.  They repeatedly assure her that that's "why they are there" and that she is "not wasting anyone's time".  She is not aggressive, she might be panicked and desperate to kill herself, but she doesn't threaten the professionals or defiantly hold up bloodied arms in whatever form the stereotype people have of these things is.  In my head I imagine a thousand doctors shrug at this moment, as if to say "what do these front-liners really know of mental illness? We give the outpatient an inch and they'll want a mile, or in this case, a precious bed on a mental health ward, meant for more deserving mentally unwell (whoever they may be).

Naturally, I'm typing about the worst attitudes to a stereotype template, but the truth is, without clear speaking from professionals, and frankly, a lot of inferences regarding "taking responsibility", "impulsiveness", "suicidal ideation" (but not "real" thoughts that are acted upon), it's hard not to assume that they think they are looking at broken selfish monsters who are best kept away from their understaffed precious resources.  By turning J away they have freed up another bed, and saved on a lot of paper work and maybe some phone calls.

Over a period of many months several professionals told J that even if she was unwell it would be very unlikely that she would be admitted to hospital.  We committed ourselves to the notion that we would be rarely on holiday, and that as the services were not catering for the likes of J, she would always be at home. We adopted a rescue cat.  We did not make the decision lightly and were determined to rectify whatever harm had come to that cat before she was brought to the sanctuary. The company and love was to be mutual. J never planned to be in hospital, at least not for long ward stays.

Again, I repeat, J never planned to be in hospital, J likes home comforts, but even she acknowledges when she needs to be kept safe until she is well.  And yet the history of her ward stays is used against her, repeatedly, and she has been accused of being "dependant upon services".  I need her to be in hospital when she is actively suicidal.  It's the only place when she can be kept safe.  If I locked her house the door when she wanted to go to a motorway bridge I could be accused of kidnap and imprisonment.  When we talk to doctors on the wards, they may ask about "triggers", but they rarely ask about the method and nature of admission - usually the very demonstration of severity of symptoms (J begging the police to take her to the motorway bridge and struggling so much that they had to put her in a the prisoner cage in a van). Recanting such details seems to feel the room with an air of embarrassment, as if they just don't have time for this.  They are surprised when they discover that J doesn't want to be in hospital and that I'm the one who has called the police (an arched eyebrow from the questioner is all I need to know that they think I've been emotionally manipulated by her apparently conniving ways).

The police have never said she was "wasting police time", and yet doctors and the crisis teams seem to feel that by saying this phrase its an acceptable way of discouraging us from asking for help. Take us to court later, I say.  I am sick of the string of anonymous consultants and social workers, and am even sicker of those that think they know J and can just say a few platitudes to fix the situation.

Okay I need a break.  I've already lost a lot of time today (will explain shortly).
This was intended to be a sort of prologue to recent events and typed sheets of request submitted to the doctors.
More to follow.