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We Can Do Better: Labelling People ‘Borderline’ Is Harmful and Pathologising

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Borderline personality disorder (BPD) is hands down one of the most misunderstood, misdiagnosed, and stigmatised mental health disorders, not only in the general population, but even more concerningly amongst mental health professionals.  

The diagnosis elicits so much controversy and misunderstanding, in fact, that many professionals are reluctant to put a label on it; while others are completely unwilling to work with clients who meet the criteria for this diagnosis. Worse yet, once someone is labelled as “borderline” it can have deleterious effects on the type of care they’re given by medical professionals, and the way they’re viewed in society. 

According to 2006 study, the stigma associated with BPD may affect how practitioners tolerate the actions, thoughts, and emotional reactions of these individuals. It may also lead to minimising symptoms and overlooking strengths.

My husband, who was diagnosed with BPD in 2019, has experienced this phenomenon firsthand. He’s been hospitalised for suicidality four times, and three out of those four times, the attending psychiatrist has basically told him to “get over it” and “choose better behaviours”. I can’t imagine any other medical setting where it would be appropriate for a medical professional to be so outright pathologising and disparaging to a patient. It’s egregious.

While a number of theories exist about the origins of BPD, most experts agree that chronic invalidation and childhood trauma are risk factors. As an MA in Counseling Psychology myself, I’d go so far as to say there’s very little distinction between BPD and Complex Post Traumatic Stress Disorder (CPTSD). 

So, if BPD is often largely due to trauma, one of the absolute worst things we can do is to retraumatise the person suffering from the disorder by shaming them, isolating them, criticising them, or treating them like they’re crazy. The second worst thing we can do is ignore them, or deny them the mental healthcare they so desperately need by sticking our heads in the sand. Yet, I’ve seen both of these things happen time and time again; both as a mental health professional, and as the spouse of someone struggling with this elusive “disorder”. 

Alarmingly, about 10% of patients seen in an outpatient setting and approximately 20% of all patients seen in inpatient settings meet the criteria for BPD. An even more concerning statistic is that over 70% of people with BPD will attempt suicide at some point in their lives, and between 8 and 10% will die by suicide, (a rate more than 50 times higher than the general population). Mental health clinicians are statistically very likely to encounter multiple patients with BPD throughout our careers, and to put it bluntly, willful ignorance can be costly. 

While the emotional volatility, high rates of suicidality, and difficulty navigating relationships can certainly make it challenging to treat or maintain close relationships with someone who has these symptoms, is the stigma around BPD really warranted? And more importantly, are the prevailing beliefs around BPD even accurate? Vehemently, no. 

There’s no easy fix to these concerning statistics, but re-evaluating the prevailing systems, labels, and attitudes around this ‘disorder’ is a good place to start. Perhaps this should start with changing the label. The term “borderline” is as disparaging as it is inaccurate. Recognising BPD for what it is (largely a trauma and attachment disorder) would go a long way in breaking the stigma. 

It’s also important to recognise that BPD is no longer the life sentence it used to be. Not only are there a surmounting number of personal memoirs anecdotally illustrating that people with BPD can and do recover, but a growing body of research supports the notion that most people who get the right type of treatment for BPD will eventually enter clinical remission. Several therapies developed in the past few decades, such as bialectical behaviour therapy (DBT), internal family systems (IFS), and eye movement desensitisation and reprocessing (EMDR) show promise for long term remission in BPD patients. 

The bottom line is mental health professionals need to be more thoroughly trained to recognise and treat people who have a history of trauma. If more clinicians could spot these symptoms and know how to treat the client, outcomes would improve drastically. 

Taking a non-pathologising approach to treatment is key. When we look at the feelings and behaviors of someone with BPD in the context of their entire life, we’ll often come to realise that these so-called “out of control behaviours” make perfect sense. When people are chronically invalidated and traumatised, they’ll find ways to adapt to their situation, often through addiction, fight or flight responses, and anxious/avoidant attachments. These coping mechanisms rarely make sense to the naked eye after the fact, but when you shine a light on how they developed, they make perfect sense. People with BPD aren’t crazy, but they were often raised in crazy-making situations. 

 It’s 2023, and it’s time to ditch the “borderline” label that was literally coined in 1938.  More importantly, it’s time for mental health clinicians to better learn how to recognise and treat complex trauma. People suffering with “BPD” are still dying by suicide at alarming rates, and the worst part is that it may be preventable. Addressing this stigma is going to require education and advocacy, beginning first in the mental health community.

Blair Nicole, MA is a member of the Forbes Agency Council.

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