Friday, 20 September 2013

Borderline personality disorder: Abandon the label, find the Person

Steven Coles

Borderline Personality disorder:
Society's illsdressed up as yours?
Picture: MargaritaJP
In 1980 the mental health industry invented a new diagnostic label, one of many, for the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III). The American Psychiatric Association (APA) presented DSM III to the world as a scientific revolution in psychiatric understanding. If people suffering emotional distress had accepted the APA's statements about the new manual, they would have rejoiced that such a wealthy and powerful organisation had put its energies into making sense of psychological suffering. The vast majority of people receiving one of these new labels had experienced great trauma - sexual abuse, extreme life events and repeated abuses of power. Quite a progressive move by the APA then: understanding the effects of power on people. Psychiatrists could show care, understanding, and perhaps even provide a sense of solidarity to people who were marginalised. Unfortunately, in 1980 the APA willed Borderline Personality Disorder into being. The APA's idea of empathy and understanding led to vast numbers of survivors of abuse being labelled as disordered individuals.

In many ways the diagnosis of BPD is an easy target for criticism and satire. The diagnosis of BPD is defined by a series of social and moral judgements, applied to people who have been traumatised and dressed up as a medical problem. If we had a friend who revealed to us after years of secrecy and shame that they had been repeatedly sexually abused as a child, our first response is unlikely to be “your personality must be really disordered – no wonder I've felt like rejecting you”. Instead we would show care, be amazed at their survival and probably feel anger at the perpetrators of abuse - basic common sense and decency. Sadly when it comes to psychiatric diagnosis good sense does not prevail. The survival of psychiatric diagnoses is in many ways an astonishing feat of magic; its supporters have woven a spell that repels good sense, compassion, logic and evidence.

 There are multiple problems with a diagnosis such as BPD. Here I want to highlight just one: it locates the problem within the individual. ‘BPD’ hides disordered environments, misuse of power and perpetrators of abuse. The following quote from Suzi, someone who received the label, makes the point better than I can:

‘I cannot understand how the vast majority of perpetrators of sexual violence walk free in society; whilst people who struggle to survive its after effects are told they have disordered personalities’ (Shaw & Proctor, 2004, p.12).

Think about the implications of that for a second. It’s accusing us of failing to recognise the abuse of power in society, of colluding in suffering. People are traumatised and hurt in many ways. For some there are obvious damaging events involved, for other people the circumstances are more complex and subtle. The flow of power is usually crucial in each. Unfortunately, the way in which we offer mental health services can lead us to ignore life circumstances and power. An understandable reaction to a horrifying life experience is converted into an illness, which a person is held responsible and rejected for having.

If that doesn't paint a pretty picture of mental health services what are the alternatives? Perhaps a little good sense might help here. We need to support people to make sense of their distress in relation to their life experiences and circumstances - survival strategies in the face of disordered environments. People need to be offered practical support and guidance, as well as compassion and care. It seems unnecessary to grab at the concepts of illness, treatment and disorder, when we can talk with people using ordinary language. Our conversations need to honour people’s survival and strengths against the odds, as well as their difficulties and needs. When supporting people who have experienced high levels of abuse and are struggling in life, workers need space, supervision and time to reflect on and cope with their own feelings, and to consider the most useful ways to help. People should not have to accept a label and the attached baggage to receive support.

Abuse and misuse of power are social and political issues. We seem to resist asking the questions that flow from this though. Such as why is sexual violence so prevalent in society? How do we prevent people doing horrendous things to each other in the first place? What economic policies decrease oppression and misuse of power in society? Going back to the 20th century, at one point the APA decided people who identified themselves as gay were suffering from an illness. Some of those who were labelled accepted and internalised the label. However due to lobbying and activism this idea was eventually abandoned. It is now time to speak up and say that people in emotional pain, who have suffered and attempted to survive, should no longer be labelled disordered. It is time to abandon the concept of borderline personality disorder and instead find and honour the person.

Shaw, C. & Proctor, G. (2004). Suzi’s Story. Asylum (Special Edition: Women at the Margins), 14 (3), 11 – 13. Also reproduced here.


Steven Coles is a Clinical Psychologist  and co-editor of Madness Contested: Power and Practice (PCCS Books, 2013). Follow him on Twitter @Steven_Coles_.

23 comments:

  1. Firstly, whether we like it or not, DSM5 field trials on BPD supported its validity. It's a real thing, and knocking it as an entity (whatever we choose to call it) isn't much cop.

    Next, the critiques you make are largely spurious. Though it's a shame when a label eclipses a person as an individual due to a poor psychiatrist, this really isn't how labels are used for the very largest part. They are used carefully, accompanied by a lot of thought, and despite your protestations, a thorough formulation and lengthy attempts at understanding the person in context.

    BPD doesn't hide disordered environments or abuse at all - psychiatrists are more than aware of the strong link between the two and a lot of the work they do is in addressing this - they recommend DBT not drugs. Claiming that they see it mostly as a medical condition is quite ridiculous misrepresentation.

    And for the record, BPD can and does occur frequently without anything close to a significant trauma - I know this disrupts your ideas but I'm sorry, really, it does carry a significant bio component.

    Neither is the diagnosis a "series of social and moral judgements dressed up as a medical problem". It's an atheoretical (not inherently medical) description, and not a judgement.

    Also, it doesn't locate the cause of the problem within the person, but it does locate the distressing effects of a problem there, just like most other diagnoses, and quite rightly. Why do you see it as different to every other diagnosis in this respect?

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    1. Angela Gilchrist Clinical Psychologist25 September 2013 11:22

      While the site offers a facility for anonymous comments, I suspect that the comment above was made by a psychiatrist. It's a pity that some professionals prefer to hide their professional identities, even when they have valid things to say. The issue under discussion is a complex one, for sure - and many psychologists would agree that there seems to be a 'significant bio component' to BPD. Neuroscientists in recent years have come out with intriguing ideas as to how our earliest attachment relationships actually build the brain structures we use for life-long relating. So perhaps the debate here is really about causal pathways, rather than the negation or admission of bio components. In my clinical practice, I don't think I've ever seen someone with a borderline label who didn't also have a very stressful attachment history. It seems unlikely that people arrive in the world with 'borderline brains', although they may arrive in the world with a predisposition which makes them more likely to developing one. But perhaps some of the evidence from neuroscience points the way by suggesting that to some extent, our brains are shaped by our experience. Indeed, if our attachment histories are imprinted on/into our brains early on, this may well explain why so-called 'borderline' presentations sometimes occur in the absence of discernible trauma. But I don't think it's up to me as a clinician to determine whether trauma is 'significant' or not. If a client tells me that what they've experienced was traumatic, that's their call. It's interesting indeed, that the writer appears to believe that he/she has the power to determine what may be 'signficant' or not - indeed, dare I say that the writer seems to think this is also something that can and should be diagnosable. And no matter how/why so-called 'borderline' occurs, it does not detract from the fact that being labelled and considered 'disordered' adds another layer of disability to a population already highly stressed.

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    2. "The battered wounded women who have survived some the worst that mankind could hand them… are consigned to the disordered
      mayhem of subcategories, clustering and anger management (Bressington 2004, p.15 – by a person labelled)

      In response to the first anonymous post above. The idea that psychiatric diagnosis is atheoretical is based on a blind faith in a supposed neutral and objective approach to understanding experience. This claim to diagnostic objectivity is hollow. This faith, often held by psychiatry and psychology, ignores the interests of those who make the judgements of others. The judgements usually made by the relatively powerful on those who have been subordinated. Psychiatric diagnosis is based on medical diagnosis - the classification of body parts. This approach leads to a reduction of experience into individual parts, which ignores the complexity of life and how humans are interconnected and interwoven with the world around them. Furthermore, psychiatry and psychology is based upon a western world view and its history riddled with sexism, racism and rampant individualism. If we ignore the interests and history that shapes how the psych industry judges people, we will continue to repeat our mistakes - we will continue to harm, rather than help.

      Lets have a look at a few of the criteria for receiving a diagnosis of BPD from DSM 5 to see if they are social and moral judgements:
      "Hostility: Persistent or frequent angry feelings; anger or
      irritability in response to minor slights and insults."

      How angry should someone feel in response to trauma, how are women expected to express their feeling about being mistreated? These are surely social and moral judgements? Surely these are based within the culture we live in?

      How above this criteria:

      "Risk taking: Engagement in dangerous, risky, and
      potentially self-damaging activities, unnecessarily and
      without regard to consequences; lack of concern for one‟s
      limitations and denial of the reality of personal danger."

      There are all sorts of sports (extreme and less so) which are rather risky. We have bankers who take very real risk with little regarding for others - though we do not seem to apply a personality disorder label to them. Would this have something to do with power? Why do we tend to label those with limited power disordered? When is a risk acceptable and in what context is this risk acceptable? These are surely social and moral judgements?

      The real question is why do diagnoses such as borderline personality disorder persist? If we look at whose interests diagnosis serves then we start to see some of the pieces to answering this question. Professional interests being a key piece of the puzzle: psychiatry and psychology being key players, both riddled with status anxiety.

      To my mind calling someone disordered is simply disrespectful and I'm unsure what is so distasteful about my suggests regarding helping people who have been hurt by life. But the last word should belong to someone labelled:

      "I think the diagnosis should be put in a wastebasket, not given to people" (anonymous cited in Nehls, 1999, p.288)

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  2. Your example of abusers walking free while the victims are labelled as having disordered personalities is disingenuous.

    They *do* have disordered personalities. This is *not* an insult.

    It's akin to saying all those muggers are walking the streets and their victims are told they have stab wounds. They do! Not their fault!

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  3. great piece! BPD cannot be reformed as a diagnosis, it's clinical code for 'you are a cunt' and that will never change, it would be like trying to fluffy up other terms with single meanings like pedophile. I know we won't be rid of classification systems anytime soon, I'd suggest combinations of the remaining diagnoses in the meanwhile (diagnoses are required for accessing things). It's applied to women who have experienced trauma, especially childhood sexual abuse, people who self-harm (even if the woman only fits the 1/9 diagnostic criteria), and others are relocated to the diagnosis if they're disliked, express dissent, or fail to respond to treatment or recover. PD is fast becoming the diagnosis of anyone failing to recover. Remove the entire category, it's worse than psychosis it's the worst diagnosis of all because it means complete invalidation as a human being.

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    1. Anonymous you have hit the nail on the head. Most psychiatrists I have met (and I have met a lot as I am a mental health professional) label people exactly as you have listed. I recently saw a psychiatrist for post natal depression (very biological, major depressive disorder, that remitted with antidepressants) but when seeking my notes, I found out he had initially misdiagnosed as BPD because I have a history of being abused as a child. Despite the fact that I met none of the 9 criteria for BPD at the time. To him, child abuse = BPD. While I finally got him to admit (and apologise for) the misdiagnosis, even in our final appointment, he claimed that childhood abuse is still a "borderline trait" even if it's not full BPD.

      Same with my experience in dealing with people who self harm. Anyone who has ever self harmed, even if they have no other BPD traits, gets the label slapped on them. Again, same with those who are disliked, express dissent, make complaints or simply fail to respond to the first antidepressant they are trialled on.

      It's disgusting but yet it keeps happening.

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  4. I wonder about the sentiments in this last comment. While I wouldn't want to go in to bat for Personality Disorder as a diagnostic category (either in terms of validity or reliability I think seeing it simply as a term of abuse misses quite a lot of the complexity associated with it. The legacy of abuse and, perhaps more importantly, neglect is all too real but not simple. As someone who has worked with many people who have attracted this diagnosis I honestly don't think it is used as a simple term of abuse all that often. Maybe from time to time but equally I've seen swings between staff becoming enmeshed in complex attachment patterns, enacting fantasies of rescue and blaming others for not being sufficiently sympathetic. This response is often not that helpful either really. Also the idea that PD is a catch all diagnosis for people failing to recover is something again I fail to recognise from any clinical team I've worked in. I have found people use PD quite specifically to try and capture elements of dependency, rejection and impulsive moods. Whether it is always used well or whether it is a good way of viewing such issues are other questions.

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    1. Listen to people damaged by it, statements such as finding forced ECT more bearable than that diagnosis. A medical student relayed to me some of her psych lectures and when BPD was raised (solely in the context of CSA and self-harm) the consultant referred to "people who self-harm are generally horrible people with no hope, and they ALL have BPD". There was also a wrist-cutting gesture within the lecture. On her psychiatric placement on questioning that consultant about it he couldn't even refer to the diagnostic criteria and said that he knew who had BPD by "just looking at them".
      People with a diagnosis of psychosis or Schizophrenia being pushed into PD groups running for 2 yrs being told by their CMHT to take that or have no support. Dependency (not sure how you define that), rejection, and impulsive moods are not the exclusive preserve of people you would define as PD. Just as self-harm and child abuse is not, despite psychiatry's insistence on reframing those experiences almost exclusively as PD. For people with the diagnosis they often have been rejected by services, I've seen women turned away after years of EDU's because their BMI isn't low enough or whatever but PD services will accept them. If anyone self-harms of any diagnosis they are at risk of attracting a PD tag purely to describe it. It's as though it's not supposed to reside within any other diagnostic category. Then the 'real' and 'pseudo' classification of perceptual differences in psychosis and BPD is laughable, especially if the person has both diagnoses. Begs the question how those experiences are differentiated. PD is attached to specific experiences including lack of recovery. I don't see the complexity you refer to, PD and BPD does the opposite it dumbs down people's experience

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    2. There are multiple studies that highlight that personality disorder diagnoses are pejorative statements - Lewis and Appleby (1988) being the seminal study: "The PD cases were regarded as manipulative, attention-seeking, annoying, and in control of their suicidal urges and debts. PD therefore appears to be an enduring pejorative judgement rather than a clinical diagnosis."

      I'm sure many staff members bring other aspects of themselves, experiences of the world and perspectives on life to the people they work with, which are more compassionate, understanding and helpful. However, the personality disorder diagnosis does not aid or nurture this, it only hinders and allows the more punitive and reactive elements of ourselves and culture to be given legitimacy.

      Lewis and Appleby (1988) had the measure of the diagnosis a quarter of a century ago: "It is proposed that the concept be abandoned". So lets belatedly heed their advice and look beyond failed categories to something more meaningful, helpful and humane.

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    3. Sorry, somewhat belated reply. I can't disagree with you Steven. I think, when you're feeling inclined, we might need to ask you for another piece specifically about the nature of the label and the extent to which it does or doesn't blame the person diagnosed. I wouldn't deny that it is frequently pejorative, I just feel that it is often more complex than simply being a term of abuse.

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    4. John I'm actually a firm believer that BPD is a real valid category but that somewhere between 90 and 99% of those labelled with it have been misdiagnosed which does a great disservice to anyone labelled with it rightly or wrongly.

      Sadly, working in mental health myself, I have seen it all too often as an excuse to abuse people. While I wouldn't say it is common, I wouldn't say it is uncommon either. What is common however is that it is seen as a reason to deny someone treatment. "Oh they're just borderline, they can't be treated" is sadly something I hear a lot.

      Considering how most people labelled with BPD don't even have it, the fact no one even tries to treat them is disgusting, but what is also so frustrating is there ARE treatments for BPD so to go around saying there are none, is bad practice.

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  5. My saddest observation of survivor supporters of the diagnosis is how they 'police' their every thought and emotion to an exhausting degree as they've been coached to, it's painful to observe.

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  6. I am currently in recovery from Borderline Personality Disorder. I started my website to try to reduce the stigma associated with it, as blatantly shown in this article. Anyone wishing to know what BPD is really like, from people who live with it every day, and Dr. Marsha Linehan, creator of Dialectical Behaviour Therapy, and a sufferer herself, please see my website: http://makebpdstigmafree.wordpress.com/

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  7. Who could disagree with the spirit of this blog? For too long people who have been diagnosed as having BPD have been regarded as "manipulative"; "aggressive" and "untreatable". The presence of abuse and trauma as aetiological factors are still understated. I don't like "Borderline" and I don't like "Personality Disorder" but I do want to point out a potentially misleading implication of this article. To say that "in 1980 the APA willed Borderline Personality Disorder into being" is to ignore the fact that the idea of individuals being "Borderline" goes back at least to 1938 when Adolph Stern first coined it to describe a group of patients under his care who he thought to be neither neurotic or psychotic. In the 40 or so years subsequent to this various practitioners continued to use the word in various contexts, some regarding it as a variant of Schizophrenia, others as a constitutional excess of aggression.

    In creating a checklist of criteria in 1980 the DSM made a significant and positive move away from the often very unpleasant assumptions of generations before. You do not have to believe we should keep the DSM to regard this development as a positive one. The negative associations and assumptions people have about BPD today are inaccurate and demeaning, but they come from people's misunderstanding and do not reflect the content of the manual.

    To suggest that "Borderline" did not exist before the creation of DSM-III, or that this group of people were not seeking help and often badly served, is to misunderstand the historical development of psychiatry.

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  8. Debra Marshall, a woman with a diagnosis of BPD speaking out about it on Madness Radio:
    http://kboo.fm/sites/default/files/episode_audio/kboo_episode.2.131007.1130.16287.mp3

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  9. "Borderline personality disorder" is indeed a terrible diagnosis to give anyone, purely because "personality disorder" cannot be anything but pejorative. Given that many (but not all) people who receive this diagnosis have been victims of abuse at some point really does add insult to injury.
    That's not to say that the behaviours listed in the DSM as typical of BPD don't tend to form a cluster. They do in a loose kind of way but again, most can be explained as learned methods of coping rather than symptoms of any kind of organic disease.
    In my own case, learning I had a diagnosis of BPD actually turned out to be a positive development, which I write about here http://stepstowardsthemountain.blogspot.ie/2014/01/marsha-linehan-at-ucc-real-change-is.html
    The reason for this is that I had been given the diagnosis but had never been informed. My parents had been told but then also told it was fairly meaningless as a label. That's true, and in a way, it's heartening that psychiatrists themselves saw the ridiculousness of the term. On the other hand I was in and out of hospital, on and off a multitude of drugs and had no idea what was wrong or how anything was ever going to change. Seeing my diagnosis in an unattended file led me to the work of Marsha Linehan and her excellent DBT programme. I am now entirely free of BPD, which is amazing if you believe its roots lie in something so intractable and so genetically determined as personality type. I don't.
    It is a pity that Linehan, for all the good work that she has done and the help it has been to so many, does not challenge the misleading and harmful term of Borderline Personality Disorder.

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  10. how can a person became mentally ill or effected by it

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  11. Thank you for this. This label literally nearly killed me and has done untold damage to so many women I know.
    It is possibly the most pernicious, pathologising, dangerous and pejorative labels in the DSM, it's European equivalent being no better. It'd be comical were it no so serious. Those bad, manipulative, splitting, promiscuous, substance ingesting, self mutilating, dangerous driving, sexually provocative, rage filled borderlines! It is bad joke of sorts but one that wields huge power over those unfortunate enough to get stamped with it. Think they treat you badly now? Wait till they label you as 'borderline'. It'll be open season on you then.
    There is a violence and violation in the application of this label, without question. It is sanctioned misogyny. The first thing you do as a professional if you legitimately want to help anyone you're working with is to not label them as 'borderline' and articles like this one really help support users/refusers/survivors.
    The very lucrative industry that has sprung up around so called 'BPD' in particular lends a legitimacy to ideas and opinions that were, at least by the late 80s in the UK, becoming increasingly questionable.
    There are a number of heartening articles, academic papers and letters to various medical journals around that time that were strenuously critical of the creeping legitimacy of the label. Sadly that was drowned out in the deluge of professionals scrabbling about for top billing in what many could see was a demographic of vulnerable women ripe for exploitation. Many of these so called therapies are a re education programme for what are cast as 'difficult, angry, miserable women'.
    Internalising a self stigma and self policing of all thought and emotion is an effective way to silence, control and 'deal with' people smeared with this label. The cult of DBT, which is essentially about silencing survivors and is rather ironically staggeringly invalidating, is just one of many. As for radical acceptance? If you're interested in Buddhism as many folks are, fine, get to it. But if you're offered DBT - run!
    One of the most dangerous aspects of this label it that any attempt to argue against it is seen as proof of it. The tag becomes a self fulfilling prophecy for professionals keen to say "look, we told you so. Non compliant, angry, labile female. She's a flaming borderline this one!".
    One of the surest ways to injure someone is to tell them the very core of their being, who they are in essence, is disordered. There is huge power to harm in that.
    If anyone reading this has been smeared with this label I want to say it is the greatest pile of nonsense this side of witchcraft and hysteria.
    The distress you may be feeling is real and you deserve help and support if you want it but the diagnosis is a gendered, invalidating, lethal fiction. The 'BPD' label has been used in the legal system to invalidate testimony of child abuse and sexual violence, support forced drugging in the prison system and have women refused custody. It is not a benign label.
    There is nothing wrong with you. You are human and possible in a great deal of pain but you are not inherently disordered or flawed. Spend your time seeking out any anti- BPD material online. It is there is you look. Clare Shaw, Gillian Proctor, Sam Warner, Lucy Johnstone, Paula Caplan, Dana Becker and many others write insightfully and often quite brilliantly on this subject.
    As patriarchal smears go BPD tops the stinking heap. Connect with other survivors and mental health workers who reject this label for the fiction it is. Good luck.

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  12. Call it what you will, but anyone who has ever loved someone with this....cluster of behaviors will tell you that it clearly isn't a fiction.

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    1. I think you misunderstand where most of us are coming from. I am firm believer it does exist. My first husband actually suffers from it rather severely. But it is extremely heavily overdiagnosed with most people labelled with it not suffering from it at all. Labelling anyone who is seen as difficult in any way as "borderline" is just as damaging to genuine sufferers as it is to those who are misdiagnosed. It leads to stereotyping that stops genuine sufferers from being able to access proper treatment.

      It is not fiction that the diagnosis exists. The fiction is the high diagnosis rates.

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  13. hi, I have a diagnosis of BPD, some people now see it as a form of complex PTSD which sounds more like what it is for me. Though doesn't take into account that as children the ways of managing our environments, our survival techniques get hardwired into our developing brains.. I hate the label and feel ashamed of being disordered. I have experienced stigma and being stereotyped. Have found compassion as well as intolerance. So what I took from your blog was empowerment, that is to think of myself as a survivor of childhood trauma and not as a survivor of a disordered mind. This helps in accepting myself and not be ashamed and continue to work on living a life worth living.

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  14. I'm glad to have read this article but, as someone labelled as BPD, I have a point to make:
    No one has written that this so called 'BPD' condition is treatable - not some permanent life long condition. With luck and good support, and in my case DBT too, lots of us move on to the best and happiest times. There are horrible stereotypes, and a fair degree of lazy ignorance, within the psychiatric and therapeutic professions,and society at large of course. More stories like mine need to be told - that despite having far more significant challenges in life to most people - I'm proud to have survived, am at peace despite the abuse, work hard to make changes in society, and am happy most of the time. The dog tag of a label will hang around me now for ever … but I bet that in a couple of decades people will look back in horror at this era of crude psych diagnostics and respect the growing numbers of us who, despite the label, turned our noses up at such malarkey, and showed the world how to behave more kindly and decently than others behaved to us.

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  15. I'm not diagnosed with anything that I know of, and certainly not with BPD. But in the 1970s I was involved romantically with someone who received that label. Whatever the nature of the traumas that contributed to her difficulties -- and I fully credit that she had been traumatized -- her behavior was manipulative, deceitful, and (yes) outright disordered. Her life remained and probably still remains characterized by one crisis after another -- a pattern which seems to be fairly frequent in people diagnosed with BPD.Under pressure from her family, she briefly saw a psychiatrist and then refused to engage with any process of change. She was discharged.

    I also read at the time that many therapists refused to take on patients in whom they recognized these patterns. There was a professional perception that therapy was rarely successful in bringing order or healing to the lives of BPD patients, and they were crazy-making for therapists themselves.

    I'm not a psychiatric professional. But I cannot help wondering: in people whose behavior seems well characterized by the DSM criteria for BPD, what proportion are able to gain improved independence and function after therapy? And in what types of therapy? Aren't these questions fairly central in the issue of whether they can be helped?

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