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Why People with Borderline Personality Are Treated So Poorly

... and the difference greater empathy could make.

Key points

  • There is a long history of stigma toward people with borderline personality disorder (BPD), even among mental health professionals.
  • New research on attitudes toward the behaviors of people with BPD suggests that they are viewed with fear and anger rather than empathy.
  • Viewing people with BPD not as "borderlines" but as people with mental health challenges can lead to greater compassion.

Stigma about psychological disorders can make life even more difficult for those who have a diagnosed condition. In certain cultures, it’s particularly challenging to face the social consequences of needing psychological help. As a result, people with these disorders have an added burden in their everyday lives beyond the actual symptoms themselves.

The whole matter of diagnosis of psychological disorders is itself fraught with difficulty. When people receive a diagnosis, they often receive a label that equates them with the disorder. You’re a “schizophrenic,” not a person with the disorder schizophrenia. Imagine a comparable situation for a physical disease. Would anyone call you an “influenzic”?

According to Pomona College’s Sara Masland and McLean Hospital’s Kaylee Null, this stigma is particularly severe in the case of borderline personality disorder (BPD). Defined as a chronic condition involving emotional instability, relationship problems, and identity disturbances, BPD carries with it a high probability of need for treatment. Rather than evoking compassion for the people whose lives are so critically impacted by the disorder, “in practice it became a literal stigma.”

How Did BPD Become So Stigmatized?

Providing some history to the origins of the term, Masland and Null point out that the very term “borderline” evolved from its initial meaning as a disorder on the “border” between psychosis and neurosis (terms no longer in use). Even in its early days, theorists described BPD “with harsh language, including ‘constitutional aggression,’ ‘infantile personality,’ and ‘pseudo-neuroticism.’” It seems like the deck was stacked at the outset against those with the disorder who were very much in need of the help that these unsympathetic professionals could have provided. Such negative characterizations, the authors note, continue to this day as clinicians continue to provide such pejorative labels to people with BPD as “manipulative,” “attention-seeking,” and “dangerous.”

You only have to think back to Glenn Close’s character Alex in the movie Fatal Attraction as a portrayal of this seemingly scary condition. At the same time, Winona Ryder’s portrayal of Susanna Kaysen in “Girl, Interrupted” also showed the punitive approach an individual with this disorder could expect to receive at a psychiatric hospital. On the one hand, Alex depicted the “scary” side of BPD, and on the other, Susanna showed the stigmatized side.

Masland and Null list a host of problems that people with BPD face in the mental health professions deriving from the negative characterizations of the disorder in the clinical literature. These include lack of empathy, a tendency to belittle the patient, and even the desire for social distancing or complete avoidance. However, the authors do point out that the success of treatments designed specifically for patients with this disorder is having a slow and steady impact in turning around these negative attitudes.

What Happens When People with BPD are Called "Borderline"

Turning next to the issue of equating people with their disorders, Masland and Null suggest that although psychiatry and psychology are moving away from this type of characterization for schizophrenia, it’s not happening in the case of BPD. As examples, even in specialized settings, the authors note, “it is common to hear patients referred to as ‘borderlines,” and mental health providers may go so far as to use language such as “'oh no, she’s a borderline,’ ‘that’s very borderline,’ … or ‘bad borderline.’”

The problem with this type of language is that such “noun labels” imply permanence of the condition as well as a loss of personhood. They create, the authors note, “greater endorsement of stigmatizing attitudes.” Moreover, noun labels used for people with psychological disorders prime the public to have more negative attitudes about mental illness in general, particularly when someone with a psychological disorder behaves in a violent way. It’s the murder and mayhem that news stories emphasize in these rare occurrences, further shaping fear of and lack of empathy for the people who actually deserve compassion and understanding.

As if all of this negative view of people with BPD wasn’t enough, Masland and Null note the additional influence of sexism. Although the prevalence of BPD is approximately equal in men and women, actual diagnosis of BPD is more likely to occur for women as an “emotional” disorder. Seeing a so-called “gender-typical” disorder in a person, real or fictional, the authors suggest, can lead people to think that the individual doesn’t have a “genuine” disorder.

Putting the BPD Stigma to the Test

With all of this as background, the Pomona College-McLean research team provided their two online samples with vignettes portraying individuals varying in disorder (in the first study) and gender (in the second study). The basic framework compared stigmatizing attitudes toward mental illness after participants read the vignette matching their condition. For the first study, in the no label condition, the person in the vignette was described without any diagnostic information other than age and gender. In the person-first label condition, the person in the vignette was described as someone “with” the disorder, of BPD or schizophrenia, and in the noun label condition, the person was described as either "borderline" or "schizophrenic.”

These manipulations involved the beginning of the scenarios in which the protagonist engaged in the same behaviors. For the BPD conditions, the protagonist engaged in multiple suicide attempts and had been hospitalized several times. For the schizophrenia condition, the protagonist was described as hearing voices and having paranoid thoughts. The second study manipulated the protagonist's gender for BPD alone. As an example, in the BPD noun label condition, the scenario began as follows: "Anna is a 27-year-old borderline…"

You can see how you would score on the stigmatizing attitude measure by rating your own views on a 1 (not at all) to 9 (very much) scale on these 9 sets of items: anger, avoidance, blame, coercion, dangerousness, fear, help, pity, and segregation. How much of each of these sentiments would you experience based on the way the person in the vignette was labeled?

The findings surprised the authors and were counter to the study’s main prediction. Participants rated the individual in the vignette more harshly when there was no diagnostic label provided at all. They were most likely to rate themselves as high on anger, blame, dangerousness, and fear when reading about the character attempting suicide whose diagnosis wasn't provided.

Digging deeper into the findings, Masland and Null were able to show that the character with the BPD diagnosis triggered more anger and blame than did the character in the vignette with schizophrenia. This finding suggests that people with BPD are viewed harshly due to their apparent lack of control over their behavior and emotions. People with schizophrenia, by contrast, suffer from hallucinations and delusions that, by virtue of their seriousness, would seem less controllable. A further nuance in the results was the higher ratings of pity toward the woman than the man with BPD. This result is consistent with the gender stereotype of women as “weak, vulnerable, or pitiable.”

If the noun label doesn’t engender more negative attitudes than the diagnostic label, does this mean that it’s okay to call people with BPD “borderlines”? Does the label not matter as long as there is some diagnosis provided? According to the authors, although the results didn’t support their initial hypotheses about the impact of labeling on stigma, they maintain that people reacted to the behaviors themselves in a way consistent with the harsh attitudes toward individuals who seem to lack control over their behavior and emotions.

Looking back at the vignettes themselves, recall that the character with BPD was portrayed as having been hospitalized many times after attempting suicide. This behavior was enough to lead people to report feeling a range of negative emotions, including blame. Why would a person who attempted suicide be viewed as blameworthy?

It’s also important to consider who was in the sample. Both online groups were predominantly White and higher in socioeconomic status than the general population. Moreover, they had no specific mental health training. Professionals would have, “through training and experience,” more “well-established ideas about BPD.” Future research could use the experimental paradigm developed by Masland and Null in those samples.

To sum up, people with BPD clearly invoke negatively stigmatizing images by virtue of their seemingly controllable behavior alone. When you’re confronted with an individual either in your life or in a work of fiction who shows these behaviors, it’s worth trying to understand the source of your own fear and possibly blame. Having greater empathy toward individuals with psychological disorders can be the first step toward giving them the support they need to find their own life fulfillment.

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Masland, S. R., & Null, K. E. (2022). Effects of diagnostic label construction and gender on stigma about borderline personality disorder. Stigma and Health, 7(1), 89–99. https://doi-org.10.1037/sah0000320

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