Borderline Personality Disorder Stigmatization
Sri Kothur, M.S., Therapist
“Manipulative,” “attention seeking,” “difficult,” and “treatment resistant” are a few deleterious ways clients with borderline personality disorder (BPD) are viewed [1]. More than any other psychological disorder BPD is viewed as the worse and most untreatable. A common view is that these clients’ take deliberate actions that they can control. These are generalizations based more in stereotype than fact.
Studies consistently show that individuals diagnosed with personality disorders encounter stigma and discrimination by mental health providers [2]. Though most studies have been international, there is ample evidence to conclude BPD is the most stigmatized of all personality disorders [3]. Stigma consists of “stereotyped, incorrect beliefs” about a group; “negative evaluation,” and “discriminatory behavior” [4]. As a result the stigmatized are susceptible to discrimination, devaluation, and decreased self-esteem.
BPD is characterized by a long-standing and negative “pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity” [5]. Prevalence is estimated at 1.6%, but may be as high 5.9% of the population. BPD rates are high in both outpatient (11%) and inpatient (20%) settings. High rates of self-harm and suicidality (8-10% to completion) are especially concerning. Clients with BPD usually have co-occurring disorders, and use more psychiatric services than any other diagnostic group.
In many cases the diagnostic label has a greater impact on practitioner perception than the client’s actual behaviors. Many clinicians are apprehensive about diagnosing this disorder, and informing the client. According to one study, 57% of psychiatrists have at some point failed to disclose a BPD diagnosis to a client [6]. Additionally, 37% chose not to document the diagnosis.
To varying degrees different types of practitioners hold negative beliefs and emotions towards clients with BPD. Several studies have found that psychiatric nurses react most negatively [3]. Research shows that a BPD label elicits negative beliefs and emotions among therapists as well [7]. It is concerning that these beliefs can drive behaviors that lead to discrimination. Private providers are not required to see all comers, and evidence indicates BPD clients are avoided more than other disorders.
One major factor that shapes provider views is a history of negative interactions. These negative interactions are due to a number of factors, including client interpersonal deficiencies and clinician attitudes. If a practitioner approaches an interaction with negative beliefs, consciously or unconscious, the subsequent interaction can be affected, and perpetuate their preexisting biases. To make matters worse those with BPD are especially vulnerable to these effects because unstable relationships are after all a defining feature of the disorder. A self-fulfilling prophecy develops. Moreover, there is a tendency for providers to distance them from the client in order to protect themselves from clients’ unhealthy behaviors. This distancing exacerbates the BPD client’s self-image problem.
In reality these clients are not hopeless, and there are specific efficacious treatments [7]. Dialectical behavior therapy (DBT) is a cognitive behavioral therapy developed for BPD. It targets areas like dysregulated emotions and interpersonal instability.
Recommendations
Respectful language
Using language like “a patient with BPD” is less stigmatizing than phrases like “a borderline” or “borderlines” because it indicates a client has the disorder as opposed to being the disorder [8].
Openness about diagnosis
Clients benefit from this knowledge when presented in a supportive and nonjudgmental way. More often than not clients react with curiosity rather than contempt.
Self-monitor
As clinicians we need to be aware of our own biases and judgments.
Education
There is growing evidence that increased knowledge about the disorder and treatment options reduce negative views clinicians have about clients with BPD [9,10]. Specialized training in therapies like DBT can help therapists feel more comfortable and in control when treating clients.
References
[1] Veysey S. (2014) People with a borderline personality disorder diagnosis describe discriminatory experiences, Kōtuitui: New Zealand Journal of Social Sciences Online, 9:1, 20-35, DOI: 10.1080/1177083X.2013.871303
[2] Knaak, S., Mantler, E., & Szeto, A. (2017). Mental illness-related stigma in healthcare. Healthcare Management Forum, 30(2), 111-116. doi:10.1177/0840470416679413
[3] Sansone, R., & Sansone, L. (2013). Responses of Mental Health Clinicians to Patients with Borderline Personality Disorder. Innov Clin Neurosci., 10(5), 6th ser., 39-43. Retrieved from http://europepmc.org/articles/PMC3719460
[4] McNab C., McCutcheon L., & Chanen A. (n.d.). Borderline Personality Disorder, Stigma and Young People. The Inspector. Retrieved from https://www.orygen.org.au/Our-Research/Research-Areas/Personality-Disorder/Research-Bulletin-BPD.aspx.
[5] Ciccarelli, S. K., & White, J. N. (2014). Psychology: DSM 5. Boston: Pearson.
[6] Sisti, D., Segal, A. G., Siegel, A. M., Johnson, R., & Gunderson, J. (2016). Diagnosing, Disclosing, and Documenting Borderline Personality Disorder: A Survey of Psychiatrists Practices. Journal of Personality Disorders, 30(6), 848-856. doi:10.1521/pedi_2015_29_228
[7] Grohol, J. (2008, April 02). Why Do Therapists Stigmatize People with Borderline? Retrieved from https://psychcentral.com/blog/archives/2008/04/02/why-do-therapists-stigmatize-people-with-borderline/
[8] Stigmatizing Patients with Borderline Personality Disorder. (2016, March 11). Retrieved from http://www.psychiatryadvisor.com/practice-management/stigmatizing-patients-with-borderline-personality-disorder/article/407316/
[9] Knaak, S., Szeto, A. C., Fitch, K., Modgill, G., & Patten, S. (2015). Stigma towards borderline personality disorder: effectiveness and generalizability of an anti-stigma program for healthcare providers using a pre-post randomized design. Borderline Personality Disorder and Emotion Dysregulation, 2(1). doi:10.1186/s40479-015-0030-0
[10] Shanks, C., Pfohl, B., Blum, N., & Black, D. W. (2011). Can Negative Attitudes toward Patients with Borderline Personality Disorder Be Changed? The Effect of Attending a Stepps Workshop. Journal of Personality Disorders, 25(6), 806-812. doi:10.1521/pedi.2011.25.6.806