Perhaps no other label in mental health stirs up more negative or conflicted associations than Borderline Personality Disorder. Because of its pejorative connotations, I know many mental health clinicians who are very hesitant to diagnose patients with BPD, or, if they do, they are hesitant to explicitly share this diagnosis. I was recently supervising a doctoral student whose patient revealed that they had been previously diagnosed with BPD. While it was not clear if the patient had a solid understanding of what it meant, it was clear that the student clinician experienced some anxiety in dialoguing with the patient about the diagnosis and ended up not doing so. Their avoidance behavior was easy to understand. The patient clearly had many vulnerabilities and it can be hard to know how to talk about the condition without sounding like there is something deeply wrong, broken, and/or unfixable or that the patient is a problem worthy of much blame. As such, talking about BPD can feel like a daunting task at times.
Because this is a fairly general problem, I thought I would share here what I told my student. Assuming that the patient did not have a clear sense of what the condition was about, I suggested that my student approach this topic by saying something along the lines of what follows. I type it here in the form of a detailed narrative for how therapists can think of this condition in a way that can guide how they talk about it with patients. Obviously, its actual delivery with a real patient would involve much more interactive dialogue and would need to be tailored to their specific situation and the frame that would enable them to best hear the description. However, I do believe a detailed description is valuable and can be shared in a way that is honest, but doesn’t result in a deep wounded, hopeless reaction.
“When you hear the term personality disorder, it makes sense that your first reaction is pretty strong and pretty negative. As such, it really is important for you to know what it means. First, you should be aware that such a diagnosis does not mean that I or any clinician can peer deep inside of you and see that there is something fundamentally wrong or broken with your core personhood. And it is not like cancer, where you have bunch of symptoms on the surface that are caused by something else (in cancer's case, cells going haywire). Instead, a personality disorder is defined by a set of symptoms. To the extent that you have the symptoms, you have a “personality disorder." If the symptoms go away, you no longer have the condition.
“A personality disorder is present, by definition, when individuals have long standing problems with their identity, which involves how they think of themselves, their self-esteem, their impulse control and such, and/or their relationships. So, the first question basically is, have you had long standing problems in these areas? And, based on what you told me, from all the conflict you had with your family and later in your romantic relationships, and all the confused and negative feelings you reported about yourself, you have indeed had those symptoms. So the term ‘personality disorder’ is a descriptive label for those long standing patterns of behaving, thinking and feeling. You should also know that, although these patterns often are persistent, research also shows that they definitely can change, and sometimes change dramatically. So it is not the case that once you have it, you always have for life.
“The term ‘borderline’ refers to a specific kind of pattern of personality problems. There are three major personality subsystems that are involved in BPD. First, there is the experiential or emotional system. Individuals with BPD have, relative to the norm, very reactive emotional systems. That is, their sensitivity to responding emotionally to events, especially negative ones, is very high. What others might perceive to be relatively minor events can result a powerful wave of emotion in individuals with BPD. Thus, negative feeling states like fear, rage, shame, sadness, guilt, and jealousy are easily accessible and often difficult to regulate.
“The second system that is involved is the relationship system. This is the system that organizes and guides ones’ intuitive sense of self in relationship to others. The key dimension in the relationship system is the dimension of relational value, which is the extent to which an individual feels known and valued by important others. Individuals with BPD usually have at least a significant part of themselves that senses or deeply fears that they have low relational value. That feeling is often a function of troubled early attachments formed with their caregivers, dysfunctional roles and relationships in their families, and/or experiences of physical or sexual abuse. Whatever the etiology, the experience of individuals with BPD is that they are judged by others as being lesser or unworthy or unlovable and that they are in danger of being neglected or abandoned or criticized or controlled. This strong sense of relational vulnerability, coupled with their emotional reactivity, makes for very volatile relationships that can be marked by, say, passionate desire quickly followed by reactive hostility quickly followed by guilt, shame and deep fears of abandonment.
“The strong emotional sensitivities and deep sense of low relational value sets the stage for disturbance in the third broad domain of personality, one’s identity. The powerful needs and feelings pull an individual’s identity, which is the conscious beliefs and values one has about themselves and the world around them, all over the map. When relationships are going well, an individual might feel ok, that they are worthwhile, that life will be good. However, when conflicts emerge, the powerful emotional and relational sensitivities drive the individual to see the world through a very different lens. One moment, they might believe that their partner is controlling and vindictive and is trying to hurt them. Later, they see themselves as being hypersensitive or maybe “crazy” and feel guilty that they reacted in such extreme ways.
“The constant back and forth, of being pulled by one’s strong feelings and needs, can lead to a fragmented, chaotic sense of self, and much self-criticism. Over time, one can come to believe one is helpless or worthless or be left with a deep feeling of emptiness. All of this internal chaos can set the stage for self-injury. Cutting or other nonsuicidal forms of injury can serve as ways of focusing, grounding, and/or distracting one’s self from the internal chaos. It can also be a symbol of rage or pain, directed at self or others. Suicidal behaviors can either be a way to solve the problem of the deep “psyche ache” or can be efforts at communicating distress or enlisting others’ aid to ward off profound abandonment fears.
“From the perspective of others, individuals with BPD are often experienced as dramatic, erratic, attention seeking, and manipulative. *Of course, such a perspective or negative evaluation is precisely what the individual with BPD fears and their first person perspective is that they are not trying to be manipulative or attention seeking. These differences in perspective are why relationships so often are tense and ridden with conflict.
“Ultimately, BPD is a descriptive label for a complicated set of issues involving heightened emotional reactivity, a strong sense of vulnerability in relationships, a fragmented, confused identity that often has many highly conflicted self-states, and a pattern of chaotic, conflicted social relations. And although these symptoms are serious, to the extent that we can figure out a way to help you grow out of them, you will no longer meet criteria for this descriptive label.”
* A sentence was removed stating that others can experience individuals with BPD as being "emotional vampires". It is my opinion that those who are in relationships with individuals meeting criteria for BPD need to be empathized with and their strong at times very negative feelings need to be identifying and accepted. But several commenters thought it was too pejorative and on reflection I agreed that, in this context, they were probably right, so I took it out.