To help my non-recovery oriented colleagues understand the stigma/resentment associated with ‘borderline personality disorder,’ I simply mention this: “Let’s say I call you and say, ‘Hey, I’ve got a referral for you. She’s been diagnosed with borderline personality disorder . . .’” I need to go no further; without fail, my colleague will smile or laugh. We both know that such a referral is a no-no, so much so that it doesn’t even have to be mentioned; it is a given.
Irvin Yalom, at a recent APA division conference, was asked if he continues to work with clients. He responded with something to the effect of, “Well I am not taking any borderline clients.” The audience exploded with laughter. From celebrity to average clinician, it is known that ‘borderline’ people are to be avoided. But wait, it’s not just professionals in the field. A simple Google search for ‘borderline personality disorder’ gets more than 248,000 hits. There are countless best-sellers on Amazon dealing specifically with the ‘disorder.’ The vast majority of the books out there, as a matter of fact, aren’t even for clinicians. Most of them are about how to live with (or otherwise be with) someone afflicted, or how to accept that you’re the one with the disease and how to get proper professional help.
There’s even a Borderline Personality Disorder for Dummies, the presence of which is either funny or sad . . . we can’t decide. Despite the spectacular array of books on the topic, it’s interesting that all of them adopt a consensus on what the disease is and where it comes from. They know, therefore there’s no reason to continue thinking about it other than to figure out how to either overcome the disease or to live with someone who has it. People who had been diagnosed ‘borderline’ have come to see us for years. Our experience of working with these people, somehow, didn’t vibe with the body of literature on the topic.
First of all, why is there so much negativity towards people diagnosed as ‘borderline’? Is it because clinicians are heartless, vindictive people? Certainly, there are some of those, but there are some of those folks in every profession. The vast majority of them, we suspect, did not get into the field to mete out cruelty upon their clients. What is it that they’re being taught that leave them so guarded?
Second, we just don’t buy that psychology and psychiatry know all that many facts about the workings of the mind. Don’t get us wrong, we think they have probably discovered quite a bit that has been beneficial, even life-saving, to countless people in the last (roughly) 100 years. But human experience is complicated, having many interacting facets and features, all of which interact in dynamic and ever-evolving ways. The field has learned a lot, but the majority of the information doesn’t represent anything like a mathematical fact. When people in the field take things as facts, we get a little concerned.
For brevity’s sake, we’ll stick with these two questions. To answer the first, let’s look at what is in the literature about ‘borderline personality disorder.’ It is considered an unremitting, debilitating biological disorder characterized by lack of empathy, being unable to adapt or grow personally, fostering vicious relational cycles, clueless as to their toxic impact upon others, severe impairment in sense of identity, impoverished sense of self, instability in regards to goals/aspirations/values, intense and conflicted close relationships, mistrustful, being emotionally unstable, generally negative, nervous, tense, anxious, depressed, antagonistic, fearing rejection, depressive, disinhibited (impulsive/risk-taking), having transient psychotic episodes, and one or many forms of self-destructive behavior . . . chronic suicidality . . . the list goes on.
By some estimates, the diagnosis is given to women 75% more than men. Theodore Millon, perhaps the world’s leading expert on personality disorders, describes four subtypes of BPD: discouraged, petulant, impulsive and self-destructive. Upon reviewing the criteria, we don’t suspect that most people would want to meet this woman. She sounds like trouble. Moreover, she sounds dangerous. Her chaotic behavior, effecting emotional storms, devouring attention, erratically putting her and others at risk reflects something more like a feral creature than a human person. No wonder people are afraid of them. This has to be one of the most stigmatizing and dehumanizing diagnoses in the DSM. It made sense to me that such a damning diagnosis must have a significant history and, indeed, it does.
Which leads us to the second question. Is this diagnosis as distinct and clear-cut as the DSM purports? Of course not. What is presented by psychology and psychiatry as a distinct diagnosis is really a social construct, the product of many years of beliefs about the (perceived) feminine gone awry. It is not just this, but is also the result of developmental stress and/or trauma. Said differently, what is deemed ‘borderline personality disorder’ is really a person with developmental stress and/or trauma in his or her background set against the context of a cultural history of the ways our culture has thought about women. Far from being biologically rooted, we have all of the data we need to now say that the cause of what is labelled as psychiatric disturbance is a function of early stress and/or trauma. Moreover, we now know that many real physical diseases are also rooted in the same causes. This is found most convincingly and recently in the Adverse Childhood Event (ACE) Study, which is consistent with a large body of research preceding it. And this applies to both men and women.
As an addendum to this idea that trauma can lead to all types of distress, we would like to make something important clear here. Trauma does not have to be a catastrophic event or a series of dramatic events happening over time. When we mention trauma, we mean any sort of experience that renders a person helpless, unsafe or otherwise finding themselves in highly unpredictable circumstances. Traumas are events that make apparent that – on some level, in our daily lives – we don’t have control over of what happens to us. And when people have experiences that really bring this truth about human experience to light, it can lead to major distress.
If so-called ‘borderline personality disorder’ symptoms are really responses to an unpredictable and perhaps unsafe environment then the real shame of it is that we are stigmatizing people that disclose the pain of our human world. We are judging people who have sensitive dispositions and absorb the world around them; people who are essentially struggling with basic life issues. And as a system – the mental health system – that sort of prides itself on exploring human behavior without judgment, this is a failure — not on our client’s part, but on the part of professionals and systems that are supposed to be caring for them.
And THIS is the real shame.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.