Borderline Personality Disorder: Stigma, Prejudice in Treatment World

When I was in training to become a psychotherapist, one of my field supervisors relayed a story about her own training at a major psychiatric facility. At the weekly team meeting, at which interns, supervisors and medical staff presented new cases, the medical director would often interrupt the presentations by making a gesture that stopped the presenter dead in their tracks. If he lifted up his hand and flashed a peace sign (a two fingered “V”),  whoever was speaking would stop and they would go on to the next case.

One day my supervisor asked what that was all about. It was explained to her that the medical director was diagnosing Axis II disorders. If he determined that the person admitted to their ward had an Axis II disorder—a personality disorder—he refused to discuss the case further. Discussion and treatment planning was deemed pointless, no medications would be used and the underlying belief was that this person wasn’t worth taking the time to discuss.

While that attitude about personality disorders is certainly extreme, and in my decades in the field at multiple treatment facilities I never encountered anything quite so blatantly disrespectful and dismissive, the negative attitudes and beliefs about personality disorders and especially about borderline personality disorder (BPD) are common. When these negative attitudes are held by people in positions of power and authority, such as supervisors and medical directors, they have the power to influence a new generation of treatment professionals and thus maintain the stigma and prejudice that has plagued people with BPD when seeking treatment.

BPD is a tough disorder to live with and a tough disorder to treat. Common symptoms include intense mood swings, unstable self-concept, severe anxiety and intolerable feelings of abandonment. Feeling needed by a person with BPD can feel like being consumed; it is overwhelming and suffocating. Holding boundaries is an important part of psychotherapy, no matter which specific technique is being used, and for a person with BPD experiencing an acute crisis, boundaries feel like abandonment. Rage is a common response to abandonment, and being on the receiving end of this rage can be hard to tolerate. In addition to the rage, people with BPD also often develop behavioral symptoms such as cutting or other forms of self mutilation, substance abuse and impulsive behaviors that may appear to be manic (such as shopping sprees or compulsive behaviors).

Being a therapist puts you on the front lines. It will never be boring. Treating people when they are experiencing this type of crisis, whether acute or chronic, will make you dig deep to be the best therapist you can be, and even then it may be difficult to make it through the treatment without feeling like a failure. Before you decide to take up another line of work, consider a few key points regarding working with people who have been diagnosed with BPD. Maintaining respect and a positive vision as a foundation to the treatment you provide can really help both you and your clients.

• People diagnosed with BPD can and often do get better. There is every reason to be hopeful. In fact, your hope and faith that they can make it through the worst days may be as powerful as other more technical interventions you use.
• Take nothing personally. Model the responses you have been trying to teach your client when you feel upset, hurt or angry about the horrible things he or she has just said to you. Take nothing personally. I am repeating this suggestion because it will be difficult and you may need to repeat it like a mantra when you are on the receiving end of angry, cutting words.
• Be real. Be yourself. Use appropriate techniques and be skillful, but don’t try to be sterile or a blank slate, unless that really is who you are.
• Use your supervision. If you don’t receive regular supervision, make sure you can get some. Peer supervision can help too. You need a place to vent and express all your fears and frustrations. The behaviors you may hear about from your client can be incredibly stressful to witness. Make sure you have a safe place to process all you hear.
• It is really easy to get angry with clients who have BPD: they seem to have an amazing ability to overwhelm, disrupt and derail your day. Find ways to acknowledge and let go of your anger. Yes, it is annoying to receive four phone calls during your lunch hour, but do you get annoyed with a person who has been diagnosed with depression when they experience sadness? Of course not. Don’t take it personally.
• Hold a vision of the person you are working with as a whole person—don’t allow the symptoms you see to take over and define the person.

There is a little bit of “borderline” in all of us, after a particularly stressful day or a sleepless night. We all have days when we feel raw and vulnerable and “on the edge.” Blessedly, for many of us, the solution is simple (a meal, a nap, etc.) and we regain our equilibrium. Maintaining compassion, respect and unconditional positive regard (yes, that old social work staple) even for people who have been “dissed” by our profession isn’t easy but it is incredibly rewarding. Viewing the toughest clients as teachers, helping us to plumb our own depths and grow, may be the most helpful attitude shift we can make.