- Borderline personality disorder is one of the most stigmatized mental health diagnoses.
- People want to be helpful to borderline individuals, but frequently find it hard not to recoil and feel defensive.
- Garnering empathy for these people can help to not take their vexing actions personally, and lead to better therapeutic interactions.
Borderline personality disorder (BPD) is amongst the most-stigmatized psychiatric conditions (e.g., Knaack et al., 2015; Ring & Lawn, 2018). Given people with BPD can indeed be more than trying at times, it's easy to become defensive around them. This lends itself to not wanting to understand, but rather scarlet letter them, and see them as simply someone to be avoided. This attitude, however, doesn't do much to help the situation, especially when it's a mental health professional.
It's been my experience that, despite the negative reactions, people want to be helpful, but interpersonally-vexing dynamics make it hard to empathize, and thus hard to constructively interact with this clientele.
Although people with BPD can be good at pushing buttons, it's our responsibility to be responsive and not reactive. Providing a recoiling or aggressively assertive response will only make someone with BPD more reactive, given the hair-trigger defensive mechanisms at play.
When teaching about BPD, I've found that putting the borderline experience in perspective with the following three considerations helps students and others better empathize. In turn, it may soften the stance towards this population, making it easier to more constructively encounter and work with them.
1. Who hasn't been a little "borderline"?
Have you ever looked forward to or expected a response from someone, but they didn't get back to you in what you consider a preferable time frame, and you began wondering, in order to brace yourself, if it could indicate some catastrophic conclusion?
Chances are, that lack of response engendered a rise in physiological signs of anxiety, followed by irritation and anger (e.g., "Don't they know I'm waiting for their reply?!"). Perhaps it's topped off with, "I'm not even going to bother with them when they do reply!" or "I waited all day to hear back! I'll give them an earful!" An impulsive, edgy, "WTF?" text or call may follow because you just couldn't tolerate your expectation not being met.
So upset were you on this occasion that it probably wasn't easy to corral that irritation and chain of events, was it?
When contact is finally made, it's discovered the person actually had a legitimate reason for not responding in an ideal timely fashion. You either then feel relief that it wasn't something about you (i.e., that you just weren't a priority) and berate yourself for sending bad energy their way, or, if you did let loose on them, only to learn it was nothing personal, you spiral into embarrassment, berate yourself to them in apology, then stew on it for days to come.
If this is familiar, you've encountered a BPD sort of experience.
Now, imagine that the above is your baseline, across relationships and situations, for as long as anyone can recall. Then, add to this that the emotions are of seismic proportions, and the ensuing reactivity is a hair trigger. Such is a glimpse of what the everyday life of someone with BPD is like.
2. There are no brakes
If you've been one to minimize the experience of those with BPD by suggesting that "they can control it if they want," let's take it a step further. As illustrated by personality disorder expert Joseph Shannon, Ph.D. (2019), it's not simply a maladaptive core schema that encourages the BPD's behavior, but we must consider the physiological correlates that contribute.
Dr. Shannon explained that those with BPD:
- Given their hypervigilance to threats of rejection, a fear-based cognition, the BPD patient's amygdala is naturally always ready to defend at full force. Think of it as a gas pedal that has no range; it can only go to the floor.
- The brakes—i.e., the prefrontal cortex, a seat of impulse control and rational thought in order to be responsive and not reactive—have no pads (i.e., the ability for rational thinking under pressure) and are unable to engage. Additionally, the brake line is partially severed (i.e., the amygdala and prefrontal cortex are not communicating well), creating interactive difficulties regarding the wish to attempt to stop.
- Lastly, serotonin, i.e., the brake fluid, is exceedingly low, further disrupting the brake system function.
With this in mind, if you've ever tried to drive a car that's out of control, you know it's a harrowing experience. You may be careening through other motorists, and though you don't want others injured, you can't help but think of yourself as you bring the vehicle to a crash of a stop.
3. Consider the child
People don't just wake up and say, "I want to make waves of tumultuous activity in my interpersonal relationships." Personalities are a complex intersection of inherited components (genetic/traits) and learned habits (characteristics) that evolve from the experiences the child is entered into, usually not voluntarily. Those with personality/character pathology more often than not encountered troubling relational experiences that encourage the development of a general maladaptive lens through which to navigate life.
In the case of someone with BPD, there is a background of early abandonment/painful betrayal, or other trauma that engenders the defensive pattern which matures into the vexing world of BPD. The push-pull dynamics, angry attacks, and desperate clinging are the result of a latency-aged kid stuck in an adult's body who is keeping up a defense against further hurt. So desperate are they not to be further pained, the maladaptive, over-the-top defensive activity is maintained at the expense of gaining exactly what they always wanted-stable relationships. Given the early relational traumas, the BPD is confusingly left to drown in their puerile, desperate attempts to somehow save themselves.
The next step
The above considered, it is not giving permission for poor behavior, or saying that those affected by people with BPD shouldn't, or don't have a right, to protect themselves and establish clear boundaries.
However, consider that, while you'd shield yourself from a car that lost its brakes, you'd likely not blame the driver/take it personally, or indeed would empathize with a child encountering traumatizing relationships. It's important to take these views with BPD patients if therapeutic interactions are not to be about the therapist, allowing space for a healthy patient-therapist relationship to germinate, and get them beyond the interactive style that's led to so many strained relationships.
Knaack, S., Szeto, A.C., Fitch, K., Modgill, G., & Patten, S. (2015). Stigma towards borderline personality disorder. Effectiveness and generalizability of an ant-stigma program for healthcare providers using a pre-post randomized design. Borderline Personality Disorder & Emotional Dysregulation, 2 (article 9). https://doi.org/10.1186/s40479-015-0030-0
Ring, D. & Lawn, S. (2019). Stigma perpetuation at the interface of mental health care: A review to compare patient and clinician perspectives of stigma and borderline personality disorder. Journal of Mental Health, DOI: 10.1080/09638237.2019.1581337
Shannon, J. (2019, October 25). Character flaws: How to understand and navigate relationships with high conflict clients. Brattleboro Retreat, Brattleboro, Vermont.