#19 – Hope, Meaning, and the Elimination of Borderline Personality Disorder

My goal for this blog has been to promote a new, more hopeful understanding of what is today called Borderline Personality Disorder. In writing this post – which will discuss hope for recovery from emotional trauma, but later argue that this hope might be better served by eliminating the diagnosis of BPD entirely – the following quote from Macchiavelli comes to mind:

“There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order; this lukewarmness arising partly from fear of their adversaries, and partly from the incredulity of mankind, who do not truly believe in anything new until they have actual experience of it.”
– Niccolo Macchiavelli (1469-1527), The Prince

For the purposes of BPD’s validity, this quote can be understood in terms of the “old order” of psychiatry – which profits both financially and via creating the illusion of scientific knowledge in psychiatrists – being opposed by those of us who argue as “reformers” that psychiatric diagnoses are invalid, unreliable and unhelpful. The reform position is that recovery from severe emotional trauma can be achieved without the need for psychiatric diagnosis. As the quote suggests, the idea that BPD does not exist as a valid diagnosis can initially be hard to believe.

Hope for Recovery, In All Its Forms

Today I’ll discuss what is among the most important topics for Borderline Personality Disorder: Hope. When a person is struggling with “borderline” symptoms – meaning intense difficulty managing their emotions and relationships, among other things – having realistic hope for improving one’s situation is critical. During difficult times, hope has felt as important for me as the oxygen a climber on Mount Everest carries for survival, or the fuel that a rocket returning from deep space uses, without which an astronaut would be doomed.

People may prefer to think of their hoped-for state as recovery, freedom, improvement, achieving goals, or something else; it is very individual. However their hope is defined, most BPD-diagnosed people express a strong desire to improve their situation.

Realistic hope

What makes hope realistic? I would suggest at least two things; 1) That hope is not taken for granted, and 2) That it is based upon convincing data.

#1, “Not taking hope for granted”, means realizing that improving one’s situation demands serious commitment and work, requires a willingness to confront oneself about difficult issues, and involves depending on other people for help.

#2, “Based upon convincing data”, means that realistic hope (for one’s desired outcome) must be based upon reliable and trusted information. To hold onto hope, a person needs a view of reality that is as accurate as possible in terms of representing the external world.

When I first searched for information about improving from BPD, a lot of what I found appeared pessimistic or even hopeless. Many publications said that the best outcome possible involved learning to better manage this painful lifelong “illness”, and some said that borderlines were untreatable or evil. Family members ranted about how difficult and unchanging their “borderlines” were. None of these things made me feel hopeful.

In earlier posts, stories and data were presented that, for me, provide realistic hope for recovery, healing, and achieving a “cure” of symptoms approximating what is described in the BPD diagnosis:

https://bpdtransformation.wordpress.com/2014/08/07/five-myths-about-bpd-debunked/

https://bpdtransformation.wordpress.com/2013/11/23/how-did-i-recover-from-borderline-personality-disorder/

The “Information War”

This data contrasted sharply with the earlier pessimistic, hopeless accounts about BPD I’d encountered. Sometimes it felt as though I was reading about two completely different conditions. For some time I fought an “information war” in my mind, trying to judge which of these conflicting versions of reality was right – or perhaps, whether both were correct, acting as self-fulfilling prophecies in different situations.  The increasingly numerous accounts I found of individuals with BPD diagnoses doing well, combined with my own life experience, eventually convinced me that realistic hope for getting better from what I then thought of as BPD did exist.

In my case, realistic hope meant that with sufficient support from family, friends, and my therapist, I had a very good chance of doing well, like many others who had encountered similar challenges before me. For other people, the hopeful narrative may be somewhat different; this makes sense given that we are unique individuals, and given my contention that BPD is an invalid, unscientific label which does not represent the same phenomenon from person to person.

Now, let us turn to look at some societal obstacles that impede realistic hope for BPD recovery.

The Failure of the American Mental Healthcare System

It can be useful to analyze the notion of realistic hope in the context of American psychiatry and its conceptualization of Borderline Personality Disorder. It is my position that psychiatry’s “medical model” approach to psychiatric diagnoses, its biological reductionism, its overemphasis on medication, and its oversimplification of an individual’s emotional struggles, all impede the spread of realistic hope regarding BPD (or more correctly, the hope for recovery from severe emotional trauma and/or the lack of healthy emotional development, in all its variations).

A Story: Emma

Let us discuss these ideas with a fictional example. Emma is a 21-year-old woman who grew up with an alcoholic, abusive father and an overstressed, emotionally neglectful mother. As a young girl, Emma was sexually molested several times by her father. Since finishing high school, Emma has lived at home with her mother, who works two jobs to provide for Emma and her younger sister. The father abandoned the family several years before, increasing the stress on the remaining family members.

Over the past three years, Emma has felt increasingly depressed and anxious most of the time. She is unsure how to make meaningful relationships with other young people. Never socially confident, Emma has become increasingly socially isolated as her old high school friends move out of town.  Due to her depressions, she cannot keep a regular job, and she goes through a series of short-term boyfriends who use her for sex and then abandon her, reminiscent of her father’s behavior. Unable to tolerate her increasing feelings of aloneness, and frustrated with her mother’s lack of understanding, she begins binge eating and purging, and also cuts herself when feeling particularly hopeless.

Finally, Emma overdoses on psychiatric medication in a desperate gesture that is really a call for help, leading her to be hospitalized for the first time. When evaluated by a doctor, she is seen as fearing abandonment by her mother, having an unstable self-image, practicing self-injurious behaviors, being unable to regulate her feelings, seeing others as all-good or all-bad, and so on. Obviously, she would be a prime candidate for receiving a BPD diagnosis according to traditional American psychiatry.

However, I want to focus on two possible ways that the hospital doctor could respond to Emma, and how these approaches might or might not promote realistic hope in Emma’s mind.

The Medical Model’s Diagnostic Approach

In the traditional psychiatric (medical model) approach, the treatment provider might communicate something like the following, “Emma, you’re suffering from a psychiatric illness called Borderline Personality Disorder. We don’t know what causes this condition, but it’s believed to result from a combination of genetic, biological, and environmental factors. BPD causes people to have problems regulating their emotions, and that is what is creating your symptoms like depression, anxiety, and rage. This is a tough condition to have – there’s no cure for it – but if you take medication and attend therapy, the symptoms can be managed.”

Usually, such an approach involves the doctor asking Emma what her symptoms are, but not going into detail about possible causes for these symptoms based on her personal history. Several emotional messages are conveyed by this approach. The first would be that there is something innately wrong with Emma. Emma would probably feel that she has a mental “disease”, that she is stuck with this illness for life, and that her prospects for finding personal fulfillment are poor.

The second message is that Emma’s past history and relationships are unimportant in relation to her “diagnosis”, or perhaps not related at all to her present problems. Rather than her current feelings and actions being understandable reactions to the deprivations she has experienced throughout life, she is told that a “disorder” is mysteriously causing her symptoms. Paradoxically, getting diagnosed with BPD does not give Emma any deep insight into why she is behaving or feeling the way that she is. The last, related message is that Emma is seen as a label, rather than as a person.

In my view, the ideas presented to Emma in the above example – i.e. “you have a psychiatric disorder called BPD, this mental illness is causing your symptoms, there is no cure for it” – are examples of outrageous lies coming from the pseudoscience that is psychiatry. In the posts below these distortions are expanded upon:

https://bpdtransformation.wordpress.com/2014/03/16/the-science-of-lies-psychiatry-medication-and-bpd/

https://bpdtransformation.wordpress.com/2013/12/09/is-borderline-personality-disorder-caused-by-faulty-genes/

https://bpdtransformation.wordpress.com/2014/01/16/a-unicorn-the-paradox-of-the-bpd-label/

In this last article – “A Unicorn: The Paradox of the BPD Label” – I originally wrote that BPD has value as a label allowing people to find help and support. My thinking here has changed, such that I would now strongly endorse only the second half of the article – i.e. starting with “Why I Do Not Believe in BPD.” As I’ve read more about how psychiatric diagnoses oversimplify people’s stories, fail to meaningfully address the causes of people’s problems, and lack scientific validity, I’ve become increasingly reluctant to attach value to the label “Borderline Personality Disorder”.

Formulation: An Alternative to Diagnosis

Returning back to Emma’s case, if labeling her with BPD is not helpful, how might she be understood instead?

The Formulation approach, which has been pioneered by mental health workers in the United Kingdom, would offer something like the following:

“Emma, you’re obviously in a lot of pain right now. From what you’ve told us, things have been incredibly hard over the past few years, and you’re not able to rely on your mother for emotional support. The way your father treated you has also had an incredibly powerful negative influence. Given your history, you must feel incredibly alone, and it’s no wonder that you feel hopeless, scared, and abandoned. Your behaviors of purging and cutting yourself make sense; after the trauma you’ve experienced, anyone might react this way to manage their overwhelming feelings.”

“Although it’s difficult, we feel that your situation is far from hopeless. But to feel better, you’re going to need help. You may benefit a lot with support from someone who can understand your story, assist you in managing your current feelings, and help you find practical ways to improve your current life. We have therapists who have successfully helped people with similar family histories to yours, and when you come to feel better and leave the hospital, we can refer you to an outpatient therapist who can continue to help you.”

Differences Between Diagnosis and Formulation

Obviously, this approach is starkly different from the traditional psychiatric approach. Firstly, Emma is not diagnosed with anything – the terms “Borderline Personality Disorder” or “BPD” are never mentioned. Rather, her symptoms are understood as perfectly logical reactions to the trauma she has experienced. In that way, Emma can start to make sense of what has been happening to her, and she will be less likely to feel crazy or defective. Emma’s past history and present circumstances are used to create a narrative explaining her present problems.

Secondly, a message of hope is strongly promoted, with the idea being that recovery is likely if Emma receives effective support. “Illness” and “disorder” are never mentioned as causes of her problems; therefore, Emma is not led to feel that there is something innately and irreparably wrong with her brain. Instead, Emma is told that her personal history matters, and that understanding how it relates to her presenting problems can help in managing her distress and improving her life.

Obviously, these approaches are poles apart, and might be considered black and white examples of how an actual mental health worker would deal with a patient such as Emma. Nevertheless, I have read about many people who are treated similarly to the first example, in which a psychiatrist diagnoses them with a mental “disorder”, while completely failing to understand the individual as someone with a history contributing to their problems. In my opinion, this traditional psychiatric approach is destructive to and precludes realistic hope.

Lucy Johnstone and Formulation

I must give much credit here to Lucy Johnstone, a British clinical psychologist whose writing on formulation inspired me. Here is an excerpt of her viewpoints on traditional psychiatry and the destructive effects of psychiatric diagnoses:

“Psychiatric diagnosis underpins the whole biomedically-based model of mental health. Any science needs to be able to demonstrate that it is based on a reliable and valid classification system, in order to develop testable hypotheses and hence the general laws that constitute a body of scientific knowledge. If this cannot be established, the whole model breaks down and all psychiatry’s other functions – indicating treatment, carrying out research and so on – will be fundamentally undermined.”

“ ‘Diagnosing’ someone with a devastating label such as ‘schizophrenia’ or ‘personality disorder’ is one of the most damaging things one human being can do to another. Re-defining someone’s reality for them is the most insidious and the most devastating form of power we can use. It may be done with the best of intentions, but it is wrong – scientifically, professionally, and ethically. The DSM debate presents us with a unique opportunity to put some of this right, by working with service users towards a more helpful understanding of how and why they come to experience extreme forms of emotional distress. We already have a situation where the strongest defence of DSM is: ‘We know it’s flawed, but it’s the best we have – what could we do instead?’ The simple answer is, ‘Stop diagnosing people.’”

These quotes come from the following source: http://www.madinamerica.com/2013/01/time-to-abolish-psychiatric-diagnosis/

Lucy Johnstone’s positions are very close to my thinking on the pseudo-diagnosis of Borderline Personality Disorder. To promote hope in people who have been severely traumatized and have great difficulty managing their emotions, perhaps it would be helpful to stop diagnosing them as “borderline.” Instead, we could understand them as individuals with unique histories that have contributed to their current problems, while encouraging them that they have strengths that can lead to recovery.

And here are some of Johnstone’s thoughts on “Formulation” specifically, in this case related to a person labeled as “psychotic”:

“In Britain, formulation is considered to be the core skill of the profession of clinical psychology… Formulation can be defined as the process of co-constructing a hypothesis or ‘best guess’ about the origins of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them. It draws on psychological theory and evidence in order to suggest the best path to recovery.  Unlike diagnosis, it is not about making an expert judgement, but about working closely with the individual to develop a shared understanding which will evolve over time…”

“We can see that the formulation is personal to (the patient), and helps to make sense of her experiences… It suggests an individual pathway forward, which will probably include developing a trusting relationship with a worker or therapist, learning ways to manage and cope with her voices, perhaps gaining support from others with similar experiences, and talking through her past. All of this is in stark contrast to the messages of shame, damage, hopelessness and despair that are conveyed by a diagnosis, and that too often lead with tragic inevitability to medication, admission and a lifetime career as a psychiatric patient.”

Source: http://www.madinamerica.com/2013/01/thinking-about-alternatives-to-psychiatric-diagnosis/

When Belief in the System Fades

In my view, psychiatry and its zoo of imaginary diagnoses militate against hope, personal meaning, and understanding. Psychiatry’s diagnosis-based ideology could be likened to a precariously perched house of cards. As more people understand that diagnoses like “Borderline Personality Disorder” are scientifically invalid, they may increasingly question the medical model underlying them. Over time, increasing numbers of patients and professionals may become unwilling to accept these labels. At a certain point, belief in the current system – the ideas that psychiatric diagnoses are real entities, that they can truly explain a person’s emotional problems, and that medication should be the first line of treatment – may fade and then collapse.

The vested interests of psychiatry will inevitably resist these changes because of the threat they pose – to making billions of dollars for drug companies, sustaining psychiatrists’ high incomes, and maintaining the fiction of psychiatrists as authorities who can diagnose emotional “disorders”. As Macchiavelli implied, the old order profits from defining reality in a way that benefits it, and some people may have trouble even considering that emotional problems could be understood in a radically different way.

Nevertheless, it is my hope that people will be open to the following idea: that promoting hope and restoring meaning for those suffering from the symptoms associated with “Borderline Personality Disorder” might be better achieved in many cases without labeling people as BPD. If some people still find benefit from being labeled as borderline, then so much the better. People ought to be free to use what works for them. But if other people are helped more by a “formulation”-like approach, one which connects their symptoms to their personal history and life circumstances without labeling them as having an “illness”, then perhaps we should shift our mental health practices in this direction. There might be still other approaches that work better for some people than formulation.

These ideas, some of which may seem confusing, relate to the arguments I have repeatedly made in previous articles: that BPD is an invalid and unreliable diagnosis, that no biological or genetic basis has been found for BPD, and that the medical model approach with its emphasis on medication is not useful for many people. For more information, the reader is again referred to the articles linked to above and their links to other websites.

The Idea of a Borderline Spectrum

However, part of me remains sympathetic to the idea of a borderline spectrum of emotional problems, which does not mean that BPD is a literal psychiatric illness. Instead, it means that people with similar-appearing emotional struggles as adults can be understood as using similar psychological defenses (e.g. splitting and projection), resulting from related histories of neglect and/or abuse. In this model, people and their problems are understood as existing along a continuum of functioning and symptom severity, and they are not understood to have the same “disorder”.

This spectrum-based model may have some value in allowing people to relate their emotional problems to other people’s (similar) problems in a meaningful way, and in allowing treatments to be developed for similar-appearing emotional problems that might be called part of a “borderline” spectrum. However, this idea conflicts with some of what I have written earlier about the lack of validity of the borderline concept per se. As can be seen from the trouble I’m having writing about it, it can be quite tricky to discuss emotional problems without using labels!

To conclude, it is fascinating how the words we choose to describe emotional problems, along with the theoretical models we base them on, are such powerful influences on our thinking and feeling about what is possible for us. I would be interested in what others think about what makes hope realistic, about formulation as an alternative approach to diagnosis, about the (lack of) validity of the medical model of BPD, and about the idea of “borderline” symptoms as occurring along a spectrum. Please feel free to share your views in the comments!

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8 thoughts on “#19 – Hope, Meaning, and the Elimination of Borderline Personality Disorder

  1. Kyra

    I so agree with you on all of this.

    The problem, of course, with a formulation-based approach is that it demands better treatment than just drugs or perhaps a DBT group. See, those are cheap, low-effort treatments. Speaking as someone who’s tried and failed to access adequate mental health treatment in the US public system, I’ve learned it’s all about money. Crazy people don’t matter enough for the government to allocate sufficient funding for individual therapy or skilled clinicians. So you get bottom-of-the-barrel clinicians and substandard treatment. After all, if it’s an incurable illness, they can justify not putting money into treating it because (according to them) it won’t make a difference anyway. Then our inadequate response to their inadequate treatment is used to prove that we’re untreatable. It’s a Mobius loop of logic.

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    1. bpdtransformation Post author

      Thank you Rainey view for your thoughts. As usual I agree with what you are saying and like your thinking (probably you think like I do!).
      Kyra, this is a tragic reality for too many people. It is such a waste because the actual/eventual dollar cost to society would be much less, if proper long-term therapy were provided, in terms of all the decades of disability that would be avoided from a relatively shorter period of treatment per person. But nevertheless, as difficult as it might seem I really hope that you can find a way to access better treatment in the future.

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  2. theraineyview

    After decades of trying to pop-diagnose my friends and acquaintances’ “personality disorders”, and reading about the sparse actual science on the topic, I’ve stopped believing in “personality disorders” at all. Even Narcissistic and Antisocial PDs, the only two that seem to be about “personality” at all, have so many different origins and trajectories that they are at best starting points, not summaries of what’s going on with anyone. And to lump Narcissists and Antisocials in with any other issues whatsoever is a cruel, mind-warping concept given that most of the other PDs seem to be, if anything, natural reactions to having been harmed by Narcissists and Antisocials. The DSMs three-cluster division illustrates that it looks at how a complete stranger presents at intake — as nervous, attention-getting or withdrawn — which tells us, at most, how the person feels about intake procedures, and perhaps not even that.

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  3. Ian

    I agree with you on this – and as promised from the email I sent – I’d write into the blog for others besides you Edward because this is something to celebrate and give more hope in the spirit of hope of this blog.

    I just celebrated making over $4,280 in one month in my business! I basically just stopped eating carbohydrates (did a very low carbohydrate diet) and cut down my caffeine intake, stopped labeling myself as anything wrong with me, started loving myself and reaching for more and taking action to pursue what I want in my life vs what I don’t want. Which of course in this context is the main struggle in my experience with severe emotional trauma because we were devalued, manipulated and shamed for our strength and pursuit of love and worth.

    Which leads me to how a backslide can happen. Right after I made these promises and stuck with them I was so grounded, confident and solid it was amazing! So much so that the girl I’ve secretly had the hots for came up to me when I was having an outstanding day and gave me her phone number, and when I saw her 2 days later I almost tripped over myself because when our eyes met it was instant smiles and chemistry I could feel!

    My wounding was significantly done by my mother previously through control, manipulation, guilt and shaming – so of course when I started to pick up the phone to call and ask this girl out I started flooding with terror and trauma (shaking and crying) of being hurt by my mother because a part of me equates women with my mother – and most of my life I’ve avoided women even though deep down I LOVE women. Very sad and frustrating for me because this woman is not my mother and don’t want her to be, but it still came up. I was eventually able to make the call – I totally geeked out on her hella nervously – but managed to ask her out. She asked if she could get back to me and I said yes, but the fact I was able to make the call was awesome even if I never hear from her again.

    I shared that last piece about the girl because it showed me even more clearly what I need to watch out for and what can trigger me into my self harming overeating/eating when scared/not hungry thing and putting down pattern. This is how I learned to survive as a child by numbing the pain and terror of the alcoholic mother with food. Since it all got set up with my mother it makes sense, but I don’t want this to stop me from dating as I grow. I really want to be dating again at some point and have the strength to lead and choose healthy, beautiful, smart, warm and loving women who choose me too!

    Cheers to hope everyone – if I can do this you can do this!
    Ian

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    1. bpdtransformation Post author

      Thanks Ian. This is a beautiful description of working through your issues. It’s great that you are having success in your business and also that you’re becoming more open to relationships with women and seeing the possible influences of the past relationship with your mother on relationships in the present. It really seems like you have much to be proud of and no reason why you cannot continue to make more progress. Well done to you!

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      1. Ian

        You’re welcome and of course thank you Edward! If there is anything I can do to support your work more or help others in this regard by sharing my experience or doing some emails/writing when I have extra time I’d be honored.

        And yeah despite how painful and frustrating it can be, I’m grateful that I’m learning to catch myself with this and have more choice and space around caring for myself so i don’t have to punish and shame myself for being attracted to and pursue women I’m interested in and curious about. That was totally one of those ways my mother tried to keep me poisoned to be a slave to her, and I now have a choice and am putting an end to the nightmare and saying hello to being the man I want to be and leaving behind a legacy of love and strength!

        Thank you Edward – and to everyone else reading this – NEVER give up – you CAN get through this!

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  4. Pingback: #26 – Why BPD Should Be Abolished, and What Should Replace It | BPD Transformation

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