Is the Idea of a Personality Disorder Outdated?
A month into my second social work placement in a psychiatric facility, I was allocated a young woman (“Cathy”) who had recently attempted suicide.
She had been found in her car with a plastic bag and ligature, a bottle of whiskey and a pyramid of sedatives. She didn’t want to be here and very nearly wasn’t.
When I met with her I was immediately struck by the way she described the sad wreckage of her life. Her face seemed calm, even at times amused, and laconic, as if underplaying the horror would make it alright for her, and perhaps more importantly — me.
It was as if she didn’t want to hurt my feelings or her own by being upset. The fear of being overwhelmed was always close to the surface, and the dark places she visited at night were not somewhere she wanted to go with me.
She was closely monitored by the nurses and her room was regularly turned over and searched for razors or knives — with good reason. After my first meeting with her, I visited the nurse’s station to check her file and was helped by a nurse who turned to a page with the clinician’s summary.
Cathy was “Axis II” and the note in her file was underlined by the nurse with a pencil and a pursing of the lips. She had been diagnosed with a personality disorder (BPD) and placed unwittingly into the category of those whose behaviour is seen as manipulative and (perhaps more tellingly) taking up valuable clinical resources.
She wasn’t really “ill,” just twisted, indulgent, and demanding. All this was conveyed in a glance and gesture.
It was the first of my many encounters in the private and public mental health systems with the judgement that accompanies a diagnosis of BPD — a potent label that’s hard for people to live down.
Cathy had a long history of trauma and recent bereavement. Her bad feelings made her vulnerable and she hadn’t developed good resources for self-soothing or emotion regulation. Did that make her a bad person or someone who didn’t deserve help?
I remember sitting with her while she worked on a jigsaw puzzle. She was perturbed by my presence, perhaps feeling that she needed to perform in some way or that I was somehow assessing her. There was an uneasy silence between us. I had made it to the other side of the professional/patient wall — but it wasn’t always a comfortable place for me.
I could understand why she was wary and mistrustful. All the system had done was to judge and label her — keeping her safe, perhaps, but nothing really therapeutic had happened during her admission. She was given meds and close monitoring — that’s about all. Perhaps that was all they could do given limited resources and the high level of risk she represented.
The label of BPD comes with a whole package of prejudices and assumptions — Winona Ryder in a white gown, wandering the bleak corridors of an upstate asylum, a young girl crying alone on a bed.
An unstable young woman with wild and unpredictable emotions, a person who is hard to get close to, someone who is reckless and often self-destructive, a person who can’t handle the ordinary pressures of life and relationships.
From within the mental health system, the view can be worse — people with BPD are seen as “using up” valuable clinical resources.
Deliberately getting themselves into the hospital and taking up beds which might otherwise go to those who have a “genuine” biological illness such as bipolar or psychosis.
They are often seen as manipulators, seeking attention through self-harm and suicidality.
Personality disorders like BPD are the black sheep of the mental health system, always acting out, not fitting in, and intransigently resisting pharmacological help.
Some people find the label liberating — finally understanding what is wrong with them and that it isn’t their fault.
But many others feel worn down by a system which often chooses judgment over real empathy, because that is much quicker and easier in a stressed and under-resourced mental health system which is focussed on through-put and risk management at the expense of human contact.
The reality for most people with BPD is that life is difficult, painful and lonely. Just to survive, day after day is exhausting. Fear can accompany every social interaction — will this person like me? Will they affirm my shaky sense of self or will they reject me?
Anticipating even the slightest hint of rejection brings people with this diagnosis into contact with the intense trauma that sits just under the surface. Abandonment is the endgame, and rather than experiencing the pain of being abandoned, they will do things that can make others less inclined to help them, often bringing about the very thing they fear the most.
Each person they meet has the potential to destroy them.
Everyday life for someone with BPD is like living on the verge of a waterfall — at the mercy of tides and the elements — the next contact could send them over the edge.
People with BPD do not have the words to describe these overwhelming mental states — they just ARE, and it feels like they are in it, now and forever, swallowed up by emotions that can’t be controlled or understood. No wonder they often want to end their suffering through suicide, or try to manage their emotions through cutting.
It’s an exhausting, painful struggle just to stay alive.
Its time we got rid of the stigma created by outmoded labels in mental health. We need to start looking at the trauma that lies at the heart of the illness. To use empathy rather than judgment and see people as humans with a history rather than problems to be solved.