When someone has a mental health issue or illness, therapists look to a diagnosis, so we can better understand it, gather information about it and treat it precisely as mental health professionals.
However, sometimes the terms themselves may add to the challenges in working with the patient. I admit, I’m troubled by the diagnostic term borderline personality disorder (BPD). The negative traits and pathologizing language usually associated with this term make it hard to use the terminology or diagnosis without also being extremely detrimental to the client. These kinds of terms can then worsen the problem of the stigma associated with mental illness, which we all have to confront. When we use certain terms, we may unwillingly subject people to prejudice, judgment and stigma that can prevent them from getting help, receiving compassion, and seeking out a trauma-informed approach to treatment. This is not okay!
Where Does “BPD” Come From?
Borderline personality disorder became a term in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. The term was intended to help mental health professionals understand a set of symptoms and behaviors for study and treatment.
Briefly some of the diagnostic criteria for BPD include:
- Impulsive behavior
- Unstable self-image or sense of self
- A pattern of unstable relationships
- Chronic feelings of emptiness
- Thoughts of suicide
- Feeling unsafe
- Feeling reactive, angry or inconsistent
Looking at these criteria from a trauma-informed perspective, we can recognize behaviors that all trauma survivors use to some degree.
Borderline Personality Disorder: Simply Another Term for Trauma Survivor
Because of trauma, individuals develop ways to cope with symptoms like these out of necessity. They adopt the behaviors we observe because they have to, feeling like these actions are the only ways they can survive.
Someone with BPD is an individual who—like all trauma survivors—uses actions and behaviors as protective mechanisms for coping with trauma or fear. Many people with this disorder grew up with a disorganized attachment style. It was difficult for them to make sense of their most important relationships and themselves. As a result they experienced a great deal of emotional dysregulation without healthy support systems or personal resources to rebalance.
The Stigma Surrounding BPD
A trauma-informed mental health professional is going to react very differently to a diagnostic term (we hope) than a person without that background.
A person diagnosed with BPD, from a clinical perspective, already doesn’t know or hasn’t yet learned how to regulate their emotions in a healthy way. That is one of the reasons they might be receiving this diagnosis. However, other people are going to respond from within their own social norms and experiences.
My issue is that the term borderline personality disorder has become so negative that it stigmatizes those so diagnosed. This terminology has taken on a life of its own, and causes many people with this diagnosis to feel shunned and rejected, which leaves them feeling more hopeless.
Sadly, many therapists even use this diagnosis as a means to exclude such cases from their practice. I know of therapists who choose not to accept people with BPD because they are the “hardest to work with.” Perhaps this label is a sign that these people are the most wounded and in greatest need of our help!
It is unfair to categorize individuals with labels that stir mostly negative responses and that don’t accurately and compassionately address the reasons behind their current behaviors and coping mechanisms.
The Need for Compassion for Those Diagnosed With BPD
From a trauma-informed perspective, I see BPD as another term for a set of coping skills used by a trauma survivor. And therefore, they deserve to be held compassionately for their survival skills – which is the only way to begin healing!
We all need to be taught or learn, directly or indirectly, how to manage our feelings, and our sense of self. Compassion is vital to empower people to seek help with any diagnosis. This includes self-compassion for the person struggling with the symptoms and social stigma that comes with a diagnosis of mental illness.
For any person in therapy, our work often must guide clients to discover how relationships can help us feel safe and comfortable. Also we must often focus on self-compassion as a resource for healing.
A trauma-informed approach includes thinking through what it means to talk about an illness with a label that may challenge a person’s sense of being okay and safety with the therapist who applies the label.
A diagnosis of borderline personality disorder is really just another way to say that a trauma survivor is willing to do anything they need to in order to survive. Like all trauma survivors, those diagnosed with BPD have developed protective parts of themselves to survive their situation because they had to. Many of these people are struggling with attachment trauma of some kind in early life, just as others, whose behavior has earned them a different diagnosis. Their early experiences, and the labels applied to the coping skills that followed, often mean it is immensely difficult for them to trust.
Can we look more compassionately at what happened to them to cause them to need such extreme coping skills? Let’s focus on what is happening inside them, versus labeling what is wrong with them.
What Do I Suggest Instead of “Borderline Personality Disorder”?
I suggest an open discussion of terminology to enable dialogue around symptoms without stigmatizing people. We need to recognize the difficulty we create for clients with labels that don’t address the why these symptoms are showing up and the failure of these terms to address the symptoms as coping skills which are treatable. Knowing their symptoms are treatable brings hope!
Our successful approach to working with all clients requires compassion and holding – the same compassion we would offer to any other client with mental illness.
We need a term that allows us to look at someone’s coping mechanisms, behaviors or actions without pathologizing them, to view them just as human beings, asking, “What made it necessary for this person to develop these coping mechanisms?” By looking at people as individuals instead of diagnoses—we can start to change the stigma around mental illness and help people heal.
Whether you are a therapist, or any human being in the world, here’s what I want you to know when it comes to BPD or any mental health diagnosis:
- Consider what happened to someone who is using these more extreme or black and white behaviors or actions. Consider what caused them to need such extreme coping skills. Consider compassionately that they are doing whatever necessary to survive!
- Don’t (ever) pre-judge someone based on that person’s diagnosis. Every person is an individual. Every individual needs and deserves individualized care. Every person deserves our compassion.
- Understand that the three stage model for trauma-informed care works for all types of trauma survivors, regardless of diagnosis.
A Note Especially for Therapists
Yes, it might be difficult to work with someone diagnosed with BPD toward their path of healing. It will require a lot of consistency and boundaries, from you as the therapist. You will need to work to teach your client secure attachment can exist in healing. These individuals have so much attachment trauma that developing trust is especially hard. Stage-oriented trauma treatment helps individuals build trust. It may take longer, but it works. Trust can grow. And from there, healing can happen! As a therapist, you have the ability and the tools to build that trust. It’s our job to invite healing for our clients.
Trauma is trauma. We need to rethink the impact of our labels on our ability to help people. We need to think twice about terms like “Big T,” “Little T,” “BPD”— or any other stigmatizing language. Trauma can be treated successfully with a trauma-informed approach. And there is hope and healing for ALL trauma survivors regardless of a diagnosis.
As therapists, it is our job to create the secure attachment that allows healing, regardless of a person’s diagnosis. I hope you are able to join me in, trusting your training and abilities to help all trauma survivors. If you are, I would like to thank you!
- This Is Why You Can’t Be In a Rush to Heal Trauma
- 9 Signs You Need Better Self-Care and May Be a Trauma Survivor
- Why a Bottom-Up Approach to Trauma Therapy is So Powerful
- Why You Need a Trauma-Informed Therapist, Even if You Don’t Think You Have TRAUMA
- Book: Trust After Trauma: A Guide to Relationships for Survivors and Those Who Love Them, Aprhodite Matsakis