Borderline personality disorder is likely the most controversial diagnosis among therapists. Borderline personality disorder treatment raises deep moral consternation for therapists, too often at the expense of patients. Being aware of those conflicts, and the quiet conversation in hushed circles around borderline personality disorder between therapists could be vital for your mental health.
In the early days of diagnosis, emotional suffering was divided by therapists and researchers into far broader categories than today (for more on the diagnostic scope creep of the last 100 years see, for eg, Diagnosis in Therapy: The jokes on you). Borderline personality disorder was placed by therapists somewhere in the middle. On one end of spectrum were what were called neurotics (or, perhaps, “run-of-the mill neurotics”) who made up the majority of sufferers who found their way into therapists' offices. Most of the cliché images we have of affluent therapy patients reclined on a couch seeking help for depression or anxiety, panic or phobias would fall into this category. At the other end were psychotics, those individuals who were seen as having lost touch with reality in one manner or another—they heard voices or experienced delusions, often paranoid. Psychotics were commonly treated in mental hospitals and received little real help until the emergence of anti-psychotic medications (which had—and still have—tremendous side-effects). Neurotic suffering, it was believed, comes from life experiences (commonly early) and psychotic suffering is organic.
Somewhere in the middle were a puzzling group. These individuals didn’t respond well to traditional talk therapy, but didn’t fit into the category of “true” psychosis. They were understood at the time as being on the “borderline” between the two—hence the term given by therapists, borderline personality disorder.
They were also incredibly frustrating. Our belief is that what frustrated therapists (and still so often does) is that the existing tools (traditional talk therapy, psychotropic medications) didn’t particularly do much to help these patients. And yet they insisted on wanting help (of course!). Further, these patients tended to struggle with intense challenges in interpersonal relationships. They were manipulative, with lots of people in their lives and, of course, with their therapists. They weren’t easy to help, and so therapists who worked with those with borderline personality disorder, prone to feeling good at helping, got frustrated.
Thus began a sordid history for those seeking treatment for borderline personality disorder. On the one hand, the diagnosis was appealing. It became code for “a royal pain in the neck” and “unhelpable.” In fact, the prevailing, formal view from therapy texts was that borderline personality disorder (as well as other personality disorders—a few more diagnoses cropped up along the way to join it) were largely incurable. The “defect” it was agreed was a personality defect, i.e. deeply embedded in the very personhood of the individual who presented with this distress.
In the last few decades there’s been an emergence of consciousness on the part of ordinary human beings who have sought help for all sorts of maladies--depression, anxiety, struggles in interpersonal relationships--about the ways that we can struggle in getting along in the world, and about the successes or failures of therapy in helping to ease or illuminate that suffering. Concurrently, therapy did some growing up with regard to developing new tools in the form of new forms of talk therapy. Along the way, younger therapists (and some older ones who were open to critical self-reflection) were startled by their own shadow: Perhaps constructing a category—borderline personality disorder—that is defined by it’s degree of irritation on the part of the therapist and that is presumed to be incurable is a problem.
Unfortunately, the keepers of the official diagnostic wisdom are among the most conservative in the field, and so the diagnosis of borderline personality disorder remains and defines the scope of its treatment, as diagnoses do. Compounding the problem was the fact that while the manner of relating to individuals who struggle in this particular way was pejorative (and got in the way of actually providing helpful therapy to those with the borderline personality disorder diagnosis) there remained a very real experience of a certain kind of suffering that this old, flawed way of relating attempted to capture (even as it failed).
Between therapists, the conflict has been resolved thusly: Those therapists who see nothing wrong with constructing the suffering of individuals who come to them for help as in a blaming, pessimistic manner embrace the term and use it as always. Everyone else avoids the term at all costs.
As with controversial topics in the broader culture, for e.g. race and gender, when the conversation goes silent we’re left without a shot at developing in regards to those matters. Those therapists who fancy themselves progressive make frequent display of their disdain for the term borderline personality disorder, thus conveying a manner of therapeutic practice free of the disdainful practice the word embodies.
But here’s the rub: While we may agree that the construction of borderline personality disorder is harmful, there is a very real, very challenging-to-deal-with sort of suffering going on, which sometimes presents itself in our therapy offices. And if you’re concerned about the harmful history of borderline personality disorder, you can’t talk about it. Ever.
So let’s talk about it. First, it isn’t an “it” at all, of course. What’s attempting to be captured is a set of shared experiences that often include:
Feeling “all over the place” with conflicting, often rapidly changing moods and feelings about oneself, ones life and other people.
A history of conflict in interpersonal relationships, often volatile and mixed in with feelings of intense love or idealization.
Self-harm, including cutting or self-punishing behaviors.
Suicide attempts or contemplation or obsession with suicide.
A history of repeated, failed attempts at getting emotional help, including from therapists, often accompanied by blame, irritation and rejection from said therapist, usually unexplained. (This one’s not in the DSM-V, but it should be.)
A great deal can be done. For one thing, we’ve got to create new tools for understanding therapy itself. Many of the old tools simply don’t work. There are certain kinds of suffering that make it quite difficult for some who seek help to tolerate the intense relating (to the therapist) that that help requires.
There aren’t any “off-the-shelf” tools. There should never be. While the borderline personality disorder diagnosis comes with its own special problems, it also suffers from the limitations of diagnosis more broadly, namely the absurdity of the idea that we can place individuals into categories that then dictate the process through which they get help. The advantage of working in collaborative therapy, particular for those who fall into this borderline-personality-disorder realm, is that the work is constructed piece-by-piece, together by therapist and patient. Collaborative therapy can only start with exactly the capacities the patient brings in to the room. We look at questions like: What sort of relating works and what sort of relating is too much (or too much right now)? How can we construct safety in a way that takes seriously how unsafe so many close encounters have likely been? How can we keep both participants safe (therapist and patient) and not resort to blaming and shaming? How can we cultivate hope?
Therapy has some shameful episodes in its past. The emergence of a discomfort in how therapy relates to the construction of borderline personal disorder is a welcome shift, but not if it denies (and leaves wanting) the very real suffering of those who seek help from therapy.
A Columbia University-trained psychotherapist with more than two decades of clinical experience, I've built a practice where my team and I help individuals, couples and families get help to work through difficult experiences create their lives.
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