#26 – Why BPD Should Be Abolished, and What Should Replace It

Do we want people to believe that BPD is a real psychiatric illness that they must manage for the rest of their lives, or do we want to promote a message of hope which says, “You can become free of your emotional distress and live the life that you want”?

By presenting BPD as a severe mental illness which can be managed but not cured, the medical model of the BPD label utterly fails to promote hope. Additionally, the medicalized concept of BPD is scientifically broken: It does not describe a valid illness which is consistent across a population.

Why do we keep using BPD if there is so much wrong with it? Is it possible that we would be better off without BPD?

And if BPD is should be abolished, what should replace it?

This article addresses how to replace BPD.

To this question, my first answer is “Nothing” – that we should simply abolish BPD – and my second answer is “Emotional Dysregulation Susceptibility Syndrome”, which I will explore as a hopeful alternative. Let’s discuss these options.

Background: The Medical Model and My Opposition to NEA and “Make BPD Stigma Free”

My central conceptual argument is that Borderline Personality Disorder as defined in the DSM is an unreliable, invalid concept. Given its current popularity, it’s not easy to fight against the prevailing notion of BPD as a valid mental illness. But after speaking to many people who also experience BPD as a flawed, discouraging concept, I am more resolute in this view than ever. If you are unfamiliar with the argument against BPD, please see here, especially Myth #5:

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

While I prefer to understand people without labels, due to practical considerations I contend that BPD should be replaced by a more hopeful label. This new label should refute the myth of BPD as a life-long mental illness and emphasize vulnerability to stress along a continuum.

My position against BPD directly opposes the thinking of many in the psychiatric establishment, including large organizations like TARA BPD, the Treatment and Research Advancements Association for BPD, and NEA BPD, the National Education Alliance for BPD.

TARA and NEA assert that BPD is a “serious psychiatric illness”, one which they can reliably investigate and for which they will create improved treatments. In my opinion, these medicalized viewpoints represent poor research and outright misinformation.

Let me list and critique some of National Education Alliance BPD’s main positions. I hope the reader will sense how badly NEA’s claims on BPD, which often border on outright lies, fail to meet the criteria for good science and basic common sense.

My Response to NEA’s Misinformation about BPD

(Source – http://www.borderlinepersonalitydisorder.com/what-is-bpd/bpd-overview/)

1) BPD is an “illness”.
NEA’s position: BPD is a single illness which causes unstable mood and behavior.
Edward’s response: BPD is not one unitary entity that causes anything. BPD is not a single illness because the symptom-cluster that supposedly represents BPD cannot be reliably identified by any biomarkers (genes, brain scans, etc.) nor reliably identified by different psychiatrists across a population, as the NIMH recently admitted.
The way a person understands their world based on past experience leads to unstable mood and behavior.

2) Genes are involved in causing BPD.
NEA’s Position: Scientists generally agree that genetic and environmental influences are likely to be involved in causing BPD.
Edward’s response: This is misleading on so many levels it’s hard to know where to start. Again, BPD is not one reliable entity. And there is no evidence that genes “cause” any of the distress-experiences denoted by the BPD misnomer – such thinking involves the mistaken assumptions that genetic and environmental factors work as separable influences in a quantifiable manner. I have written about these distortions extensively in my article on twin studies (#4).

3) Brain scans provide evidence that biological factors cause BPD.
NEA’s position: There is evidence that biology is a factor in causing BPD, due to imaging studies in people with BPD showing abnormalities in brain structure and function.
Edward’s response: Does NEA think the public cannot understand basic cause and effect? Of course seriously distressed people have observably different brains than “normals”. That doesn’t mean biology or genes cause these differences; neglect, abuse, and lack of love, which are much more prevalent in those labeled “borderline”, inevitably lead to different brain functioning. But that doesn’t even mean those things cause BPD or that BPD is real. Never take a difference for an illness.

4) Biological factors make people more likely to develop BPD.
NEA’s position: The current theory is that some people are more likely to develop BPD due to their biology or genetics and harmful childhood experiences can further increase the risk.
Edward’s response: The current theory is a demonstrably false hypothesis. Constitutional vulnerability to stress may make it easier for some people to become overwhelmed by environmental stress, but that doesn’t mean that BPD is in any way a valid illness, nor that such people cannot become well. Plus biology and genetics do not act alone in the way implied in this reductionist model (see – http://www.madinamerica.com/2015/06/are-dsm-psychiatric-disorders-heritable/ )

5) The prevalance of BPD can be quantified.
NEA’s position: BPD affects 5.9% of adults at some time in their life
Edward’s response: Does anyone really believe that a subjective, descriptive label with no biomarkers can have its prevalence reliably identified to a tenth of a percentile?

6) BPD is a life-long mental illness.
NEA’s position: People with BPD have BPD for life. (NEA stops short of saying this outright, but they imply it. Their website talks over and over about managing and reducing symptoms in “borderlines” of different ages, never once mentioning the possibility of becoming free of “the illness” or discussing the possibility of full recovery)
Edward’s response: This is one of the most damaging myths being promoted about BPD. Problems that are mislabeled BPD can be fully recovered from; people who once approximated borderline criteria can eventually live a satisfying, emotionally normal life. Many thousands of people have already done so. Getting better is hard work, but people do not have to cope with and manage BPD for life. People need real hope, not the discouraging prospect of a life-long illness.

My Manifesto Against National Education Alliance for BPD

As can be seen, NEA BPD set themselves up as the experts on how to define and treat the BPD “illness”, an illness label they obviously intend to keep. But they may not have considered that former “borderlines” can see through their propaganda.

My position on NEA’s “BPD as a serious psychiatric illness” notion is this:

  • Severely distressed people do not have accept the label BPD as an identity nor as an explanation for their problems.
  • Emotional problems are not reducible to “psychiatric illnesses”, nor are they the exclusive province of psychiatry.
  • Effective help which often leads to full recovery from problems mislabeled BPD already exists. Recovering does not require the assistance of “experts on BPD”, nor does it require DBT and medications, although these can help. Also, people can have their own definition of recovery and a meaningful life.
  • Emotional problems mislabeled BPD can be completely healed and do not have to be managed for life.

It’s time to say goodbye to National Education Alliance’s harmful theories about BPD as a life-long psychiatric illness, to end the borrowed time these theories have been living on.

Why Reducing BPD’s Stigma is Doomed to Failure

I also oppose the message of blogs that attempt to put a positive spin on BPD, like “Make BPD Stigma Free”. In my opinion, reducing BPD’s stigma and building “BPD Pride” is doomed to failure. To me, these efforts resemble shifting deck chairs around on the Titanic. Similar attempts to reduce depression’s and schizophrenia’s stigma have foundered miserably; the problem is that reducing complex emotional issues to medical labels explains nothing and fails to empower people.

Two examples of such programs are instructive:

  • “Defeat Depression”, a large scale British campaign to reduce the stigma of Major Depressive Disorder, failed to reduce stigma and did not improve outcomes according multiple follow-up studies.
  • “Beyond Blue”, an Australian attempt to reduce the stigma of so-called mental illnesses, also backfired. Studies investigating its effect found that those who knew less about mental illness diagnoses, or who were given a diagnosis but rejected it, had better outcomes than similar people who believed they “had a mental illness.” This unsettling finding has been confirmed in John Read’s research (e.g. Models of Madness).

The disturbing conclusion of this research is that accepting that you have a “mental illness” – as opposed to rejecting the medical model of emotional distress – actually decreases the chances of recovery. This shocking Youtube presentation by critical psychiatrist Sami Timimi covers this and other eye-opening facts about “mental illness”:

If Defeat Depression and Beyond Blue failed to destigmatize depression, why should a destigmatization program for BPD succeed? Alongside “schizophrenia”, BPD is the most unreliable, invalid, confusing, harmful, stigmatized, and useless label. Even if BPD were to lose its stigma, it would remain an unreliable term that explains nothing about an individual’s problems.

Abolishing BPD – The Ultimate Goal

Borderline Personality Disorder can and should be entirely abolished. BPD should be consigned to history as a tragically misguided way of
concretizing emotional distress.

Here is how a world without BPD would look:

1) No More BPD Diagnoses: Distressed people would no longer receive the BPD label during hospitalizations or psychiatric consultations. They would be understood as individuals using the Formulation approach to distress (see article #19 here – https://bpdtransformation.wordpress.com/2014/12/04/19-hope-meaning-and-the-elimination-of-borderline-personality-disorder/).

2) Label-Free Treatment: Psychotherapists and treatment programs would help distressed people without viewing them as borderline, no matter how much the client “fit” that outdated term.

3) Label-Free Family Understanding: Families would be helped to support their distressed members without being fed the fiction that their loved one “has BPD.” Parents, siblings, partners, and children would find that their loved ones’s problems can be understood without calling them borderline.

4) A New Research Paradigm: into severe emotional problems would cease to be focused around BPD. It would instead use the emotional dysregulation spectrum concept that I’m going to discuss. There would be more qualitative, experience-focused research, and less quantitative label-focused research.

5) Abolition of BPD and the DSM: BPD would be abolished from the DSM, as it has already been removed from ICD (Europe’s version of the DSM, from which BPD was recently voted to be dropped). Furthermore, as an unscientific fraud full of fictional illnesses, the entire DSM would be eviscerated.

In time, BPD would be viewed as an outdated relic, a sad symbol of an age where psychiatrists constructed bizarrely misguided labels for emotional distress. People in the year 2200 would look back on “BPD” in disbelief, much as people today look back at centuries-old conceptions of physical illnesses. BPD would be mocked alongside notions of evil spirits released by bloodletting and plagues caused by divine curses.

A BPD-free world is possible. People often underestimate what can be done over long periods of time with sustained, gradual effort. Perhaps BPD’s life is already growing short.

How Would We Understand People Without BPD?

What a scary idea! How could we ever understand people showing “borderline” symptoms without labeling them with BPD?!

How do we understand the problems of anyone we care about?

1) Listen to their story. Learn about what past and present experiences are causing their distress. Develop a shared understanding of their problems based on their history.
2) Learn about what they want to change in the future. Develop a shared understanding of their needs and dreame.
3) Understand fundamental human needs for security, dependence, respect, and independence.

These are the fundamental steps in the Formulation approach to emotional distress, as described here in the story of Emma:

https://bpdtransformation.wordpress.com/2014/12/04/19-hope-meaning-and-the-elimination-of-borderline-personality-disorder/

People labeled “borderline” can be effectively helped without labeling them as BPD. But because of the reductionist ideology that has crippled the minds of too many mental health “professionals”, abolishing BPD without a replacement label may be a bridge too far. The Big Pharma profit incentives which maintain the need for medicalization of emotional distress present another obstacle.

The First Step Toward Abolishing BPD – A New Name

Supported by the public’s ignorance about what a precariously perched house of cards “BPD” really is, the profit motives of psychiatrists and Big Pharma will likely block a total abolition of BPD, even though BPD paradoxically never existed and does not exist today. Therefore, I suggest the intermediate step of renaming BPD, something which has already begun to happen for other pseudo-illnesses such as “schizophrenia”.

If done well, renaming BPD would accomplish multiple goals:

1) Undermine the false conceptualization of emotional distress as an illness that is consistent from person to person.
2) Emphasize that emotional distress varies along a continuum and that people labeled “X” are not always “X” (i.e. are not always distressed, but are vulnerable to stress).
3) Reduce stigma by introducing a fresh name without negative connotations.

Despite these hopeful goals, one might argue that replacing BPD with another name would lead to just as much stigma and misunderstanding.

But could a new name truly aspire to be as miserably uninformative as Borderline Personality Disorder?

Would BPD by any other name smell just as bad?

I doubt it.

Japan, Jim Van Os and the Abolition of Schizophrenia

I’ve gone through some brainstorms about what BPD could be renamed, drawing on the campaign against “schizophrenia” for ideas. Many people are calling for schizophrenia to be abolished, and Japan legally abolished schizophrenia about 10 years ago

(Yes, there really are no more “schizophrenics” in Japan. They have a new, less-stigmatizing name for psychotic distress, meaning “integration syndrome” in Japanese, and people undergoing psychotic episodes are no longer called schizophrenic. The entire Japanese government-recording and psychiatric-labeling system for psychosis has been changed. See here – http://www.schres-journal.com/article/S0920-9964(09)00140-6/abstract ).

Jim Van Os, a Dutch psychiatrist, created a website labeled “Schizophrenia Does Not Exist” here: https://www.schizofreniebestaatniet.nl/english/

Van Os renames schizophrenia, “Psychosis Susceptibility Syndrome” , or PSS. The name implies that psychotic experience occurs along a spectrum of severity, involves vulnerability to environmental stress, and that people who have been psychotic in the past are not always psychotic today. In this model, “schizophrenia” as a discrete illness is meaningless and false.

Taking Van Os’s lead, I suggest replacing Borderline Personality Disorder with “Emotional Dysregulation Susceptibility Syndrome”, or EDSS.

The Emotional Dysregulation Susceptibility Syndrome

If BPD were renamed Emotional Dysregulation Susceptibility Syndrome, what would that mean? The EDSS concept would contrast with BPD as follows:

1) Spectrum, Not Illness: EDSS represents a spectrum or continuum of increasing vulnerability to emotional distress. Despite similar appearances, people vary along this spectrum both in degree and kind of distress experienced. People would have more or less “EDSS” in relation to others and themselves at different times. EDSS is therefore not one illness, but a spectrum of related conditions – it refutes the misrepresentation of BPD as an internally reliable illness.

2) Vulnerability, Not Illness: EDSS represents a heightened susceptibility or proneness to emotional distress, usually correlated with neglect and abuse in childhood. EDSS itself does not cause distressing symptoms; rather, it represents the heightened likelihood of environmental stress causing these distress experiences. Compared to BPD, EDSS gives more weight to what happens around a person, rather than to isolated non-contextual internal experiences. EDSS is a syndrome – again meaning it represents similar-appearing experiences which do not necessarily reflect a consistent underlying illness.

3) Recovery and Freedom, Not Management: EDSS represents a psychological state that someone can be in at a certain time of their life, but can grow out of and be free from at a later time. It is in no way a lifelong condition. With effective help, people have a good chance of moving out of the EDSS spectrum for good. This refutes one of the most damaging lies about BPD: That BPD is a life-long illness.

(If you could rename BPD, what would you call it and why? Or would you keep BPD? Let me know in the comments.)

A Psychodynamic Model of the EDSS Continuum

Drawing on my psychodynamic background, I conceptualize Emotional Dysregulation Susceptibility Syndrome as a continuum marked by a relative deficit of positive self/object images, combined with a predominance of all-bad images of self/other within a person’s mind. The deficit of good internalized experience and the predominance of all-bad self/other images would usually correlate with neglect, lack of love, abuse, or trauma caused by parents and peers in childhood and young adulthood. I developed this model fully here, drawing on the “master theorist” of borderline-spectrum conditions, Ronald Fairbairn:

https://bpdtransformation.wordpress.com/2014/02/02/the-fairbairnian-object-relations-approach-to-bpd/

The deficit of all-good images leads to the inability to comfort oneself when under stress (i.e. emotional dysregulation), and to the increased susceptibility to stress relative to most emotionally-healthy people who had more consistent past and present support. All the other distress experiences commonly labeled “borderline” – e.g. destructive acting out, lack of identity, rapidly shifting moods, extreme rage, splitting, etc. – would be understandable results of having to cope with the missing self-comforting functions that can only be provided by a predominance of good self/other images over bad self/other images, i.e. enough good experiences in one’s past to reassure oneself when under present-day stress.

These distress experiences would also be understood as present-day replayings of past trauma; i.e. as the projection of the all-bad self-object images internalized in childhood onto others in the present, which make the person experiencing EDSS feel that they are “bad” and others are rejecting or unavailable.

EDSS might also be conceptualized as the spectrum encompassing the “Out of Contact” through “Ambivalent Symbiotic” Phases in this 4-phase model:

https://bpdtransformation.wordpress.com/2014/02/08/four-phases-of-bpd-treatment-and-recovery/

These descriptions do not represent an illness, but rather a dynamic state of relating to oneself and others at a certain time. One can function at any point along the spectrum from almost Non-EDSS to very severe EDSS – i.e. from approaching a normal range of being able to comfort oneself and function well, with only occasional regressions into serious distress – down all the way to very severe EDSS, in which the distress experiences are constant and severe to the point that normal functioning is not possible. Hopefully that the paradigmatic differences between BPD and EDSS are clear.

You Don’t Have to Accept the BPD Label

I hope these ideas will be encouraging and provoke thought about whether BPD really is valid and useful. Replacing BPD might seem unthinkable now, but there were times when women voting seemed impossible, when black people being free seemed impossible, and when tobacco causing health problems seemed impossible. Radical change can happen. Often, the process leading to a dramatic change is gradual and unseen, like when decades-long pressure building under the Earth’s crust goes unnoticed before an earthquake.

If a small but growing number of people reject the BPD label, this process can build momentum toward renaming and/or abolishing BPD. I encourage everyone reading this who has ever been labeled “borderline” to consider that you no longer have to identify with or accept BPD, period.

If a psychiatrist labels or has labeled you as BPD, or if the voice of people calling you borderline is stuck in your mind, I encourage you to tell them something like this:

“The BPD label you’ve called me is a simplistic checklist of distress factors, factors which anyone under stress for long enough can experience to different degrees. There are no reliable genes, brain-scans, or other biomarkers which can identify so-called BPD. In fact, BPD is in no way a reliable classification; it is an “illness” fabricated out of thin air without a basis in real science.
There is therefore no proof that I have an illness like you say, or that there is anything innately wrong with my brain; most likely, I am reacting in a perfectly logical way to the stresses I’ve gone through. There are other, better ways to understand my problems, and I do not accept the false label of BPD that you are putting onto me. If I get enough help, I can fully recover and live the life that I want.”

Psychiatrists and therapists need to hear this from more of the people they call “borderline”!

27 thoughts on “#26 – Why BPD Should Be Abolished, and What Should Replace It

  1. Brian Self

    BPD is bullshit Matt – right on – look forward to the day that dehumanization of people ends! And go ahead and take me off the mailing list, I’m taking my focus off of mental illness and focusing on career growth and women/romance/dating – and feel free to reach out to me anytime in friendship or if there is anything I can do to support the work you are doing in the future.

    *Brian Self* *541.292.7965* *Linkedin.com/in/brianself007 *

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    1. bpdtransformation Post author

      Brian thank you, I didn’t forget about you and am glad to hear you’re focusing on positive things. I actually cannot remove you from the mail-list though – I’ve tried, but apparently you have to do that somehow through WordPress or your email yourself. Anyway, I will be in touch.

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  2. Natasha Shapiro, ATR-BC, LCAT

    Reblogged this on Musings of an Art Therapist/Artist and commented:
    This is great. I am completely in agreement and glad I saw this post. Just a few days ago I was thinking about how BPD is an insulting diagnosis, as those suffering from it have nothing wrong with their personality. Most early attachment issues are caused by early multiple childhood traumas in an invalidating environment which causes extreme trauma. Based on my clinical experience and readings, I don’t think BPD is useful anymore, and that emotional dysregulation really describes the extreme PTSD biological and environmental symptoms that indicate the diagnosis. The current BPD name does not match this emotional , mental and spiritual disorder. Being on the Borderline between neurosis and psychosis as it was originally observed, is more a reaction from doctors, how they felt around people with this condition. It does not match the condition itself.

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  3. luckyotter

    I’m realizing BPD is a stigmatizing name for another disorder not recognized by the DSM–Complex PTSD (C-PTSD) but the psychiatric community does not recognize that a “traumatic event” does not have to be a single incident (such as war or rape) but can be a longstanding pattern of abuse–and that’s the only “difference” between a person diagnosed with BPD (which has an array of symptoms far too diverse to be a single PD) and one diagnosed with PTSD. You already saw the article I wrote yesterday about that.
    I’m tired of the “evil and crazy” stigma BPD gets — people back away slowly when I tell them I’m borderline and I’ve had therapists refuse to treat me because I was considered “hopeless.” Hell, even NPD (which BPD is too often compared to) isn’t hopeless! Do you think the NPD label should be abolished too? I’m curious.

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  4. Felix

    I appreciate your perspective as someone who was diagnosed with BPD, however, I wonder about the family members, partners (ex and otherwise), etc., who walked this path alongside. I agree with much of what you say, but I do see mental illness and illness in general as a societal issue with many equally valid perspectives. When one is involved in a toxic and abusive relationship with someone who is also wearing the label “BPD”, it is not the label that harms the partner, but the behaviours of the sufferer. It is those very behaviours that are often so stereotypical that they have become part of the criteria used to diagnose. I agree that a medical model may unduly pathologize, and therein lies the rub of stigma, but until an effective therapy can be provided the catch-22 will remain. There must be some handle onto which the therapeutic paradigm can be affixed, otherwise therapies are thrown at it randomly as if grasping at air.

    Natasha, your comment regarding BPD (I assume you refer to the phenomenon of BPD, not the label), “….those suffering have nothing wrong with their personality”. Really? That is a profound departure from what the literature accepts and concludes. I would be very interested to read anything that explains personality disorders otherwise.

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    1. bpdtransformation Post author

      Felix, Thank you, there are a lot of interesting points in your comment.

      There is a lot of value in varying perspectives; I learn even from those perspectives with which I mostly disagree.

      You’re totally right, it’s behaviors/experiences/the way someone relates that matters much more than the label, which is just a word.

      As for “effective therapy” – did you mean to make it sound like there isn’t yet an effective therapy for people labeled BPD? As I’ve written about in several other articles, many people have been “cured” of BPD and become mostly normal and healthy, as impossible as that sounds under the medical model. And many others have improved greatly, getting better enough to live well while still having some lesser amount of distress. My articles about the therapists Adler, Seinfeld, Masterson, and their work discusses some of these case studies. In the medical model, most of what you read about is short-term therapy or DBT (i.e. management), and that’s not enough, because you need a loving, trusting relationship with a therapist or other parent figure over several years to overcome severe borderline symptoms.

      Regarding the handle idea, you have a point here… but that’s why I think EDSS would be better (or if anyone else has another idea, I’d like to hear it). IMO a great reconceptualization of personality disorders is from Lawrence Hedges (e.g. the book, Working the Organizing Experience). I need to write about that. He reframes BPD as the symbiotic self-object experience and focuses on ways of relating or not relating, over and above simplistic symptoms.
      Lastly about “those suffering with BPD have nothing wrong with their personality” – this is true in one sense, and not true in another. What Natasha meant I think is that they are not bad people and there is nothing biologically/innately wrong with people labeled BPD (i.e. they have the potential to heal, be free from borderline distress, and relate in a healthy way). This is true. On the other hand, there is certainly great distress and much “wrong” in a subjective sense with the way that people labeled BPD relate to others and are (un)able to handle their feelings when they are in the “borderline zone.” So your point is right also..

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      1. Felix

        Thank you for your response. Ironically for me, the word, “cure” in my opinion, offers far more potential for damage than does the very label of “BPD”. To be “cured” implies the very medical and reductive framework that does not apply well to the mind, but from what you have read (and I applaud you for your well written articles), you understand such limitations. So I guess what stands out is the question of whether it is the actual label, “BPD”, or any label? I honestly think that merely changing the label, calling BPD something else, would do little in the long run. Some people will take offence no matter what and this same discussion could happen ad nauseum.

        As for “effective” therapy for PD’s, using BPD as a specific example, DBT is the new vogue in psychotherapies and while it has shown promise for some symptoms and for some people, it certainly is not THE cure that many people wish it was. The literature simply does not support that. Nor does the literature support other therapies as THE cure. The condition requires a commitment that many of the suffers may not possess. It is hard, and painful and requires the sufferer to accept the here and now, including the responsibility for their own behaviours and while some people can achieve that, many cannot and drop out. The attrition rate for psychotherapies is staggering, yet this is not often discussed when the proponents of DBT (and others) are blinded by the excitement of novelty.

        Your response to my comment about what I read in Natasha’s comment, “those suffering with BPD have nothing wrong with their personality” is kind, however, if she meant to say what you interpret her meaning to be, then that is an entirely different idea. Yes of course sufferers of BPD (and every single other mental illness) are human. Yes as well, many times their behaviours are inhumane, and that was my point, and yessiree, they sure do have something very deeply wrong with their personality. I just viewed a 60Minutes taping that came out recently about Belle Gibson that has left me speechless, and while there is no mention of PD, the subjective feeling of cognitive dissonance that the viewer might experience would offer good practice in seeing distorted thinking as it lives and breathes.

        love your blog!

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      2. bpdtransformation Post author

        I agree “cure” is not a good word for transforming the way one relates and feels. The semantics of these debates is difficult. My mentor once said to me, “No one gets completely better, but we can get better enough to live well.” That is a better description than cure.
        I’d argue that the literature does support long-term intensive psychodynamic psychotherapy as a potential “cure” for borderline conditions, but yes, the willingness and commitment to stay in treatment have to be there, and also the finances or willingness of the therapist to accommodate to what the client can afford have to be there. By long-term psychotherapy I’m talking about at least 2-3 meetings a week, for 3-5 years. If you read books like Vamik Volkan (6 Steps in the Treatment of Borderline Personality Organization), Gerald Adler (Borderline Psychopathology and Its Treatment), James Masterson (Psychotherapy of the Borderline Adult), this type of work can be very successful when the resources and willingness are there. And, I optimistically think many people labeled BPD would eventually engage in this type of work, if the resources/awareness/money was available. Most people want help despite sometimes appearing otherwise. But a lot of the poor outcomes we are seeing is a result of lack of resources, the profit incentives of Big Pharma to provide pills and not medication, and also the pessimism and lack of awareness about full recovery being possible.
        The attrition rate for psychotherapy is often high, as you said, but also varies dependent on many factors. In my article #22 I wrote about a 3 year, 2x weekly trial of schema therapy for 45 people labeled borderline in which a very high proportion of the people stuck it out and many recovery fully or greatly improved.
        I’d argue that part of the reason DBT dropouts may be high is because DBT is not such a great approach for many splitting/borderline behaviors. In my biased opinion, DBT is overly directive / focused on managing a person’s problems, and is based around an illness paradigm. Considered pychodynamically, in some cases DBT may serve to reinforce splitting and increase the divisions between the bad object/good object views in a person’s mind, ie. the style of DBT can make the person feel controlled/directed in the same directive/controlling way a person was treated in the past.
        As for there being something “wrong” in the personalities of people labeled BPD… sure, many times their behaviors are inhumane / disturbing. It makes sense, given how inhumanely and disturbingly many of them have been treated in the past; it is the only way many of them know how to relate before learning a more healthy way to relate.

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  5. Felix

    Thank you once again. Not to kick a dead horse, but just to do some math here…. Picking round numbers to illustrate the point, if a sufferer is faced with what you offer as one route, and we remain modest, if that person attends 2 sessions per week, for 30 weeks per year, and they complete 2 years of therapy, and again, for ease of addition, each session cost $100, then that amounts to $6000 per year (modest)! Given the reality that there is a genuine reluctance on the part of the mental health professional community to offer a diagnosis for BPD for reasons that include as you allude to in your article, the lack of discrete bio-markers, or reliable and valid diagnostic tools for insurance purposes, then this is a financial barrier that will prevent most people from using such therapies. Furthermore, sample populations used for research purposes in efficacy trials of therapies such as DBT, etc. may over-represent effectiveness of those therapies for individuals in society at large.

    But even before therapy effectiveness can be discussed, the fact that denial can be so strong a defense mechanism and as well, the egosyntonic nature of the illness means that some large proportion of sufferers may simply feel that there is just nothing wrong with them–it is someone else’s problem. Most may never walk in the door.

    I agree that it is possible for sufferers to find some improvement, but for many, the deck seems stacked against such success at this point.

    Thanks again for a great blog! Your writing and knowledge base are top shelf!

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    1. bpdtransformation Post author

      I’ll answer this. Yes, the overwhelming majority of people do not get long-term intensive psychotherapy or would not seek it anyway. Your numbers were quite low estimates; doing an intensive long-term psychotherapy could be much more expensive.
      So no most severely distressed people – who of course come disproportionately from poor and low-middle class backgrounds, due to abuse and neglect being more frequent in those social classes – cannot afford as much therapy as they might need.
      But…. the irony is that not paying for them to get such help is actually costing our society more in the long run. Because within 3-5 years not all, but many of them could be profoundly helped and enabled to function/work without needing disability income / continuing hospitalizations. But as things are, the large majority of them are not able to contribute much to the economy, and/or they become a drain on the economy for decades via disability income, Medicaid, etc. So our society’s short-term focus on managing the “mentally ill” with medication and short-term therapies is going to backfire. Along with peak oil, climate change, resources like water being depleted, the national debt, and so on, it doesn’t make me feel that optimistic about the long-term future.
      As for “the illness”, I do not think that is a valid conceptualization of these variable and individual forms of emotional distress and suffering. Yes there are people labeled “borderline” who are heavily in denial who would not seek help. But there are a surprising number who want help and understanding, but simply don’t have the financial resources or knowledge of where to get good help. If you read Psychoforums, PsychCentral, Reddit, or other forums, this is apparent. Hopefully this blog is a drop in the ocean of help they need.
      Thanks again for your comment, I can tell you have a curious thoughtful mind.

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    2. tahrey

      The counterargument to the therapy cost barrier of course is… how much does long-term medication cost? What of involuntary protective hospitalisation? And all the many different negative economic impacts that may come from allowing someone to suffer under the condition’s yoke, reducing the quality of their life and others’, possibly damaging property, wasting doctors’ and police time, maybe ending up in prison, or killing themselves (or even committing murder)?

      Considering the ludicrous cost of most medical treatment in the US, including simple pharmaceuticals, six thousand dollars doesn’t really seem like a great hill of beans.

      Of course it might be a bit more of a skewed thing in places where the cost of therapy is actually a lot more than the cost of medicine, or other frontline public health treatment, but such places generally have a fairly good grasp of how preventative treatment, or helping someone overcome a “curable” but otherwise life- or lifestyle-limiting condition can reap a payoff many times that of the original investment over the rest of their natural life.

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  8. Melvin D

    it is funny reading this post, which i agree with, because i have been fortunate enough to avoid a BPD diagnosis even though i was a textbook case. all the therapists i’ve had have given little credence to the DSM and the medical model, choosing instead to focus on individual stories… so what i am saying is the world you want to see already exists in many quarters.

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  9. Math

    Hello,
    I just discover your blog and I am very happy because I’m french and your blog is very very interesting!
    I’d have a question for you, do you think a good therapy can be pursued by skype ?
    Congratulation for your recovery, you are very inspiring.

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    1. bpdtransformation Post author

      Hi Math, thank you for your comment. I do think this is possible yes. I don’t see why not. It depends on the two people and if they can feel connected. You might search on Google and see some articles about Skype therapy.

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  10. Megan Hoffman

    To anyone who wishes to abolish BPD as a diagnosis, I would simply ask if you’ve ever actually been Personally Involved with someone who has BPD. I am the daughter of a mother with undiagnosed BPD, and let me share with you a bit about the toll it has taken on my family. I cannot possibly share everything, because the damage has been so deeply ingrained, but I will try.

    Whenever someone asks me what it was like to grow up, I simply don’t know what to say. I don’t know where to start. I guess I’ll start here: I find myself deeply saddened, grieving the loss of the childhood I Should have had. I find myself angry and confused, suffering from pervasive PTSD and anxiety symptoms due to chronic childhood emotional and physical abuse. And I am Deeply, Deeply angry at the therapist my mother saw for nearly 15 years–the one who diagnosed her with PTSD, anxiety, and chronic depression, instead of addressing the real situation. Perhaps the therapist was a moron and couldn’t see the signs (my mother has high-functioning BPD, so perhaps she was simply able to hide it from even her therapist like she hid it from the rest of the outside world). Perhaps the therapist simply didn’t want to “add to the feelings of worthlessness” my mother had by placing such a “debilitating” diagnosis on her head. I’ll never know for sure–but here is what I do know. I’ve already stated that I have frequent symptoms of PTSD and anxiety, and I’ve even gone through bouts of depression (due to situational circumstances AT HOME), but I have NEVER. NEVER. acted in ways my mother has consistently acted throughout her life.

    BPD is a severe diagnosis. One that yes, may resemble other things, but is clear and distinct in itself. And because my mother was misdiagnosed (or I should say properly diagnosed but the therapist casually left out the largest issue brewing in the pot of mental struggles), she has INSISTED throughout her entire life that she ONLY has PTSD, Anxiety, and Depression, and NOTHING ELSE. And since that has been officially backed up by a license therapist, everyone in my mother’s life simply believed that claim. That claim was used by EVERYONE–including myself– to excuse my mother’s inexcusable behavior. I truly believe that had my mother received the correct diagnosis, much of what I’m about to write below could have been avoided and properly addressed.

    Here is why BPD needs to be properly addressed and called out for what it is. This disorder has ripped apart my family entirely–making all our lives, my mother’s life most of all, Utter Hell. For those in her inner circle, she has a particular talent for making other people think and feel like they’re going insane. My mother would go into violent rages frequently. The loving, adoring memories I had of her when I was a small child were replaced by constant fear of what she would do next, oftentimes at the drop of a penny. She would literally be punching me in the face–and she wore some thick rings–over and over again. And if I did ANYTHING to defend myself–If I put my hands up to protect my face, if I pushed her away from me, she would either A. Become angrier, scream louder so that spittle would splash across my face, and say “HOW DARE YOU HIT ME YOU LITTLE *insert whatever verbal abuse you’d like*, OR B. fall down dramatically and burst into tears, begging my older sister to help her up, help her to walk, while bawling that I had physically hurt her–effectively making my older sister and anyone nearby believe I was the aggressor. And even if my older sister had seen exactly what happened, her reality was so deluded that she entirely believed my mother. All our realities were so deluded, that I literally questioned my own sanity. Option B was the worse of the two possible reactions, because it instantly turned my anger and–yes– hatred towards my abusive mother into guilt and sympathy towards my aggressor–into blaming myself.

    This was my mother at her worst–she was physically violent for a span of about 4 years, until I finally ran away and placed myself into foster care. But she has always, always been chronically emotionally abusive. Every single person who has stepped into her inner circle at one time or another would experience it–the emotional manipulation. The gaslighting. The EXTREME verbal abuse. I can recount one experience in particular where I had gotten into an argument with my mother earlier in the day. That night, I walked into the room–terrified–to let her know that I was about to hop in the bath. (Because her control issues are SEVERE, she had say over even our most basic bodily functions. Sometimes we had to literally get permission to use the restroom). As soon as I let her know, she looked me in the face and said, “Good, I hope you drown in the bathtub.” I was 13 years old. I have recounted this experience multiple times to her, and every single time she says, “That’s crazy. You’re crazy. How could I ever say something like that?”

    The worst part of all this was the main way she had us all convinced we were crazy–by appearing completely or mostly normal to “outsiders.” She would complain and complain endlessly about her horrible children to her friends, to anyone that would listen. She’d literally get her friends to chastise us over the phone on our “bad, uncontrollable” behavior. We were simply bad kids. The night I ran away from home, there was an incident where I was balled up on the living room floor while my mother was kicking me repeatedly as hard as she could. Both of my sisters were sitting at the dinner table less than ten feet away, witnessing the whole thing. When I later recounted this incident to social workers, my older sister got on the phone with me at my mother’s command and called me crazy–said it had never happened. My mother even had all the social workers convinced–whenever I’d recount something to them, they’d say something along the lines of, “What?! That happened?? Your mother doesn’t seem like that at all..she loves you so much…” and they’d try to convince me to return home. And this is the scariest part of high-functioning BPD. No one on the outside can see it, and people on the inside are living in some sort of warped reality based on what the BPD person thinks is real…so you truly believe something is fundamentally wrong with you, and that if you could just be better, could love more, then things would improve.
    To this day, my mother will not admit to any abuse occurring in our household–especially not to physical abuse. She simply cannot face the things she has done–she lives in a separate reality. Every single one of her personal relationships is marked by extreme conflict. My sisters still live in warped realities–they have not escaped, and for the most part still accept all of my mother’s behaviors as being their own fault. No one–including my mother’s entire birth family–can manage to stay in her life for very long, and it has caused her to be mostly alone for as long as she’s been alive. Even my sisters and I only speak to her out of familial obligation, love for our mother, and extreme guilt (minus me, I don’t feel guilty one bit because I have come to recognize my mother for what she is–deeply sick). Intimacy is what she craves most–love is what she craves most–and she cannot see how she destroys any chance of having it. THIS IS WHY BPD NEEDS TO BE PROPERLY ADDRESSED AND TREATED. Had that therapist even once told her, “hey, I think there is something deeper happening here.” My family would have been more prepared to deal with the disorder that for so long has left us confused and alone, thinking we were all at fault. And perhaps my mother today, would have been able to overcome this Very Treatable issue and would be living a happier life. BPD IS DANGEROUS to not only the sick individual, but to every single person around them. Children, who are the most dependent, are ESPECIALLY VULNERABLE.

    PLEASE, TAKE THIS SERIOUSLY.

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    1. tahrey

      No-one’s failing to take it seriously, or suggesting that the conditions currently labelled as BPD aren’t potentially severe, to the point of destroying families, or even fatality. The author himself has spent time, against his will, in a mental hospital, following a failed suicide attempt. If it was a toytown condition, there wouldn’t be such a strength of feeling aimed at improving how it’s dealt with.

      The thrust of the article is that the current method of diagnosing, labelling and treating the condition (or vague symptom cluster, at least) is woefully inadequate, and leads to many people – both the patient themselves and their friends and family – needlessly suffering over the long term, as it’s positioned as an intrinsic, intractible state of being, where the only recourse is to keep them zombified on strong meds for the rest of their life, and taught a few mildly effective CBT coping strategies.

      Whereas with a better, more diversified, and indeed positive understanding of the exhibited symptoms, their causes, and how the patient can be taught to overcome them and regain a more balanced, stable worldview, they have a strong (approx 4 in 5) chance of full “recovery” – having a happy life with normal, fruitful relationships, with both the people they already know and yet new acquaintances. Again, as demonstrated by the author himself.

      …or are you just feeling personally attacked by the suggestion that it can be brought on by poisonous and abusive relationships within the family, especially originating with a bad parent-child relationship? The amount of anger sizzling off your post worries me.

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  11. tahrey

    Quite an amazing analysis. Have you considered going into writing medical texts yourself, or more up close and personal activism rather than just a blog?

    There’s quite a few shades here of something I’ve otherwise experienced with a journey into autism- and dyslexic-spectrum diagnoses. That’s also another field where the general cluster-analysis model of psychological conditions falls down pretty hard. There’s quite a bit of overlap between those two spectra, and several others such as OCD, ADHD, etc; the picture you start to get is that human psychology is – and it seems almost laughably obvious when you write it out loud – a much more complex thing than the neat cut and dried syndrome labels in the DSM or ICD or whatever would have you believe. We’re all actually a bundle of hundreds, maybe thousands of different individual, narrow traits, that express with variable strength. Get a particular clump of them together, enough otherwise independent little abilities or disabilities or particular ways of thinking or sensory responses, of the necessary strength to put your aggregate score over a somewhat arbitrary boundary figure, as determined by some primitive study a half century or more ago by some random researcher, and … pop! You have Aspergers. Or Dyspraxia. Or BPD.

    Of course, that makes things a lot simpler for a doctor assigning a diagnosis, or medication, or a course of therapy, and for action groups and charities to spike awareness and attract funding for their particular cause, but it doesn’t necessarily make it accurate, or even largely correct. My own group of symptoms is a weird grab bag from across that whole ASD/DSD/etc field where there’s probably enough accumulated disability / impairment to register as an all new syndrome in its own right, but separated out into those prebaked clusters, I don’t register particularly highly in any of them. Enough to qualify for a “processing disorder” on the dys-whatever side (one feels they were clutching at straws when assigning that), and aspergers / “some autistic traits” on the other, plus a few additional neuroses for flavour. There’s some aspects of APD that I recognise, but maybe they’re actually just the ‘sperg… or a side effect of the depression-stress-anxiety(-anger) that it provoked, and has merely been stabilised, rather than done away with, by medication. It’s also probably why I see some familiarity in both BPD and CPTSD, but would never test out as having a high enough score to actually be labelled with such – a paradox that I wasn’t quite able to square away until independently coming to that realisation, and then seeing it backed up first by researchers or commentors in those other fields (including a couple of rather insightful, last-ten-years TED talks given by e.g. connectomics, fMRI, and applied psychology researchers), and what you have to say throughout this blog.

    Because, really, it’s all bollocks. The inconvenient, messy reality is that everyone has their own personal mental spectrogram. A nice wide chart where there are various spikes and troughs according to the different mental “wavelengths” that typify each part of your personality. The whole thing needs thrown out and rebuilt from much more wide ranging analyses, and everyone taken as their own unique self, where the dozens of unique high points can be leveraged for success and happiness, and the lows dealt with directly on their own terms, rather than as bizarrely optional factors of specious, broad-brush syndromes. If actual correlated clusters are actually found when that full spectrum analysis is done and a statistical big-data approach is taken to seeing whether certain strongly associated groups of traits do exist, and can be freshly labelled as true, large-cohort conditions (and, indeed, illnesses), then… that’s still good. It makes the job easier, and at least we’re doing it with a much more solid backing than was previously possible – vs the opinion and personal experience of one doctor, or a small research group, with a small and probably quite biased sample population looked at in one or two isolated studies somewhere wayback in the 20th century…

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