Borderline Personality Disorders: Past, present and future?
The diagnosis of Borderline Personality Disorder (BPD) carries with it plenty of myths, misunderstandings, and stigma. Even healthcare professionals haven’t formed clear language around it until very recently. This, in part, is why there is stigma around a diagnosis of it. Psychiatrists in 1930s America used the term ‘borderline’ to describe patients who exhibited both Neurosis (mild mental health illnesses that were considered treatable, such as depression, anxiety, obsessive behaviour - all maintaining a grasp on reality) and Psychosis (a severe mental disorder that is so impairing that the patient lost any sense of reality and considered, at the time, incurable). These patients, psychiatrists thought, would regress into psychosis or borderline schizophrenia.
The 1970s saw a more nuanced approach to BPD with the development of Transference-focused Psychotherapy (TFP) by Otto Kernberg. Kernberg was heavily influenced by Freud and Klein. His therapy aimed to allow patients to gain better control over their behaviour, develop more nurturing relationships, regulate themselves better, and pursue life goals. It did this by supporting patients to accept parts of themselves, building up healthier coping strategies and establishing one’s identity (or in TFP lingo, integrating representations of self and others, development of primitive defence mechanisms and the resolution of identity diffusion that perpetuate the fragmentation of the patient’s internal representational world).
Stigma towards people with BPD ranges from the myth that they are lazy, have low motivation, or cannot maintain relationships, right through to them being dangerous and unpredictable. Many people living with a diagnosis will internalise this stigmatisation. Some living with BPD have an overwhelming internal critical voice that compounds stigma and societal myths.
Anyone can be at risk of BPD. However, a vast majority of people living with it have survived severe relational trauma at some point in their lives. For this reason, substituting a diagnosis of BPD with a suggested experience of Complex Post Traumatic Stress Disorder (CPTSD) feels far more appropriate. This change refocuses how symptoms are treated and how patients and society view the diagnosis.
Saying someone has a Personality Disorder can suggest there is a ‘problem’ with the patient. It communicates to the patient that their personality - their very way of being in the world - is disordered. This can provide a lot of ammunition for the internal critical voice as well as stigma from society. However, if we say a person has CPTSD, we are saying something physically and/or psychologically catastrophic has happened to that person. They may struggle, not because they are the ‘problem’ but because the repercussions of historical trauma still need processing.
With my clients who live with BPD, much of the work we do together is around examining incredibly painful life experiences, such as sexual, physical, emotional abuse or neglect as children and the effect that has had on their adult lives. Doing this helps to turn down the volume on their pain and critical internal voice. In the therapy, we move away from the stigmatised idea that the client is, in some way, the ‘problem.’ By doing this, stigma and internalised stigma lose their power, and the client can accept that they are not flawed or broken in some way.
Who gets BPD?
“Estimates of the prevalence of BPD vary between 0.7 and 2% in the general population. It is estimated to be present in 20% of in-patients in psychiatric wards and between 10 and 30% of out-patients.” (NICE)
BPD is mainly diagnosed in women (75% of people diagnosed with BPD are female), and its prevalence is considerably high in the prison population; in England and Wales, it is estimated to be 23% among male remand prisoners (held while awaiting trial), 14% among sentenced male prisoners and 20% among female prisoners.
It is vital to understand that data on mental health is often unrepresentative. For example, women are more likely to seek professional help than men and are therefore more diagnosed. Impacts of racism and discrimination within the mental health services and healthcare systems also exist. For more on this, read the Race Equality Foundations literature review of Racial Disparities in Mental Health. (Your identity does not mean you are predisposed to BPD or any other mental health difficulty. It is a societal issue whereby groups who face discrimination also face a larger struggle with health and social inequalities).
What is BPD like to live with?
Navigating everyday life can be excruciating for someone living with BPD. The smallest things can be emotionally devastating, and no one around you seems to understand. Swinging from impulsive and sometimes risky behaviours to crushing depression and suicidal thoughts. Relationships can be tough. A person with BPD can become incredibly attached to a partner, analysing everything in the relationship, from tones of voice to the time it takes to respond to text messages. This puts a significant strain on them and their relationships. BPD comes with stigma too and is misunderstood, often thought of as dangerous or unpredictable, and this can become alienating to someone living with the disorder. The charity MIND have a great page describing the DSM-5 symptoms HERE
Of course, as we increasingly view mental health disorders on a spectrum, a person does not need to meet all the diagnosable criteria to have BPD. This means that people will experience it differently, including different symptoms and different severity of pain.
The way we think about BPD is slowly changing. As broader awareness about mental health grows, our approach to clinical care changes too. Yet, it is far too slow, and this slowness is the determinant of those living with BPD. A common treatment for BPD is Dialectical Behavioural Therapy (DBT), a type of cognitive behavioural therapy that tries to spot negative thoughts and increase positive behavioural changes. A patient can get this therapy on the NHS, but only with a diagnosis of BPD. A patient whose diagnosis of BPD compounds internalised stigma, a critical self-view, or is harmful will need to identify as having BPD regardless to access help. Conversely, a patient who gets a diagnosis of CPTSD and not BPD will not access DBT. Getting the appropriate treatment on the NHS depends entirely on getting an increasingly out of date, uncomfortable and stigmatising diagnosis.
A diagnosis helps professionals communicate and determine the treatment required by a patient. However, the diagnosis itself should not further compound the patient’s suffering, and it certainly shouldn’t limit their access to which help they can receive.
What can mental health professionals do to help?
Make sure the majority of diagnoses are patient led. This means not only explaining the meaning, symptoms and rationale for the diagnosis, but sense-checking that the patient agrees and feels the psychological assessments are correct. Explain what support accompanies a diagnosis and signpost to organisations where they can get additional support.
Create space for clients to investigate what diagnosis means to them. This can include challenging internalised stigma and creating space for clients to question, accept or reject a diagnosis. In addition, where possible, support clients to navigate the healthcare system in order to receive the most helpful care they can get.
Be activists in and outside the therapy room. Do not be neutral when it comes to combating stigma both in our professional networks and with our clients. We need to challenge harmful ideas and associations, be that within a clinical setting or within society.
A lot has changed for people living with BPD since the 1930s, but sadly societal and some clinical attitudes have been slower to move forward. With understanding and conversations about mental health opening up, there has never been a better time to challenge old ways of thinking and pave a new way to thinking about serious mental health issues.
Borderline Personality Disorder: NICE guidelines
Race Equality Foundation Report