“But whatever you do, between now and our next session, DON’T google Borderline Personality Disorder. Why? Because you aren’t going to like what you read. A lot of it will be misinformation, and it will make you out to be a monster. You have a treatable mental health diagnosis, with a very good chance for recovery…I know you are probably going to google this anyway when you get home. What you read is probably going to freak you out. When it does, call me so I can help you check the facts about what you are reading. And, consider going to www.borderlinepersonalitydisorder.com, or even Wikipedia. “
This is my standard speech to people, after we discuss their diagnosis of Borderline Personality Disorder (BPD). I didn’t start out giving this speech. I had to learn the hard way, along with my fabulous clients, how much misinformation and stigma there is towards people with BPD. Many times I have seen patient who clearly had BPD documented in their charts, but who were never told. I didn’t start out my career intending to advocate for people with this disorder. But after watching the prejudice and discrimination my patients faced, even in their own health care offices, I realized I had to speak up.
It’s not hard for most mental health providers to diagnose people with Borderline Personality Disorder. The hard part seems to be bringing themselves to tell their clients, in an upfront, factual way, about the diagnosis, or even just entering the diagnosis in the medical record to begin with. In fact, you are more likely to hear a therapist verbalize that a patient “is borderline” than you will see it actually written down. “Borderline” becomes code for “bad patient.”
Borderline Personality Disorder (BPD), like the symptoms it consists of, is a condition full of opposites. It has one of the highest mortality rates of all mental health diagnosis (estimates suggest that 3-10% of people with BPD die by suicide), but despite its lethality, it is one of the most villianized disorders among clinicians. It is fairly common in places like community mental health centers (where about 1/5 of the client population might qualify for this disorder), but clinicians often intentionally do not diagnose it directly in the medical chart, preferring instead to reference it “between the lines” often saying they don’t want to give a client a bad “label.” I know of few other mental illness diagnoses to which clinicians attach so much moral judgment on the people we serve. And at the same time, there are evidence-based therapies for BPD, with high rates of successful outcomes, including full recovery.
Can you imagine your primary care doctor refusing to diagnose or even talk to you about a highly treatable condition that has a 3-10% chance of killing you?
And yet, this is the case in mental health clinics everywhere, everyday. The misinformation and stigma about BPD is so profound it is hard to get good information about this common disorder from most clinicians, or even a basic internet search.
When I was approached about writing this essay, about what it is like to help people with Borderline Personality Disorder, in just a thousand words, this is what leapt out to me. The challenge is not helping the people with BPD (though that does involve a fair amount of clinical skill). The real challenge, in my experience, is the overwhelming cultural change that needs to happen, within the mental health field, so that someone with BPD can trust that when they are seen by a licensed professional they will be accurately diagnosed, and accurately informed about their disorder.
There are decades of rigorous research about treatments like Dialectical Behavior Therapy (DBT, one of the gold standard, evidence-based treatments for Borderline Personality Disrder). The facts are that people with BPD who are accurately diagnosed and provided with DBT have a very high recovery rate. However, despite this, good clinical training around BPD is rare.
This is particularly troubling to me, given how commonly BPD occurs among the people with whom I might work in most general outpatient settings. Can you imagine going to a doctor who does not know how to diagnose or treat a common illness? And who will blame the patient for continuing to be sick and struggle as a result? This exact dilemma is one that faces people with BPD every day.
I’ve heard that living with Borderline Personality Disorder is like being an “emotional burn victim.” That’s how Marsha Linehan describes it, and she should know. She is one of the major researchers and developers of treatment for this disorder…and someone who has recovered from it. She has used this metaphor to describe the incredible emotional pain and sensitivity that people with BPD experience every day. That description always moves me to compassion. Now, imagine what I have frequently witnessed…that same person in excruciating emotional pain being dismissed, misdiagnosed, given ineffective therapy, and then blamed for not “wanting to get better” or being “manipulative.”
I find myself wishing, while writing this essay, that my biggest concern was getting the world to understand and fight the stigma of Borderline Personality Disorder. But considering that many people have not even heard of BPD (despite estimates that 1 in 20 people will have it over their lifetime, and all of us will know someone with BPD), that desires seems a little aspirational.
Most days, my biggest wish for people with Borderline Personality Disorder is just that licensed mental health professionals would be better educated and more aware of our own prejudice and discrimination towards BPD. After all, professionals are the ones the public trusts, the ones the public looks to for information and guidance. If we can’t be relied on to be educated, competent, and compassionate towards people with BPD, who can be?
April C. Foreman, Ph.D., is a Licensed Psychologist serving Veterans as Suicide Prevention Coordinator for Southeast Louisiana Veterans Health Care System. She also serves as Suicide Prevention Lead for Veterans Integrated Service Network 16, a region of Veterans Affairs. She is passionate about helping people with severe (sometimes lethal) emotional pain, and in particular advocates for people with Borderline Personality Disorder, which has one of the highest mortality rates of all mental illnesses. She is known for her work at the intersection of technology, social media, and mental health, with nationally recognized implementations of innovations in the use of technology and mood tracking. She is the 2015 recipient of the Roger J. Tierney Award for her work as a founder and moderator of the first sponsored regular mental health chat on Twitter, the weekly Suicide Prevention Social Media chat (#SPSM, sponsored by the American Association of Suicidology, AAS). In the recent years this chat has become one of the largest and most active mental health centered social media communities on Twitter. Her dream is to use her unique skills and vision to build a mental health system effectively and elegantly designed to serve the people who need it.