Harm of Stigma with Borderline Personality Disorder

“Manipulative,” “attention seekers,” and “drama queens” are a few damaging ways clients with borderline personality disorder (BPD) are often described; these individuals are among the most stigmatized within a clinical population (Allan, 2018; Deans & Meocevic, 2006; National Alliance on Mental Health, 2017). BPD is a disorder centered around pervasive patterns of instability in the context of emotion regulation, interpersonal relationships, self-image, and impulse control (American Psychiatric Association, 2013). Stigma towards psychological disorders creates added difficulty for those who have a diagnosed condition, attributing to greater apprehension about seeking treatment and exacerbating feelings of hopelessness. Stigma specifically related to BPD often becomes a self-fulfilling prophecy on behalf of the clinician. Preconceived negative views towards clients become reinforced at the emergence of challenging symptoms (i.e., maladaptive attempts to self-soothe, intense vacillations of mood), creating hostility towards the individual as opposed to conceptualizing such as symptoms not yet successfully treated (Aviram et al., 2006).

Although clients with BPD hold a significant prevalence within the clinical population (~20% of inpatient population, ~11% of outpatient; Chapman, 2023), they are often the subject of negative attitudes and/or judgements from mental health professionals, resulting in—often due to clinician’s own fear or anxiety—a reluctancy to treat. Antagonistic feelings towards those with BPD are often the result of common suicidal tendencies, including perceived around the clock availability from the therapist, as well as strong, negative countertransference feelings, such as anger, embarrassment, and helplessness (Bodner et al., 2011). However, both fears of overwhelming burden from and hostility towards those with BPD are often an indication of treatment failure or clinician inexperience (Gunderson & Palmer, 2012). In fact, those with more severe symptomology have even been shown to have a greater potential for symptom improvement, particularly a decrease in maladaptive behaviors, challenging the longstanding idea that those with BPD cannot progress in therapeutic treatment (Barnicot et al., 2012).

Current Treatments and Gaps in Research for Borderline Personality Disorder

Once considered an untreatable mental disorder, BPD is now successfully improved with several empirically supported approaches of various theoretical orientations, such as those derived from cognitive, psychodynamic, psychoanalytic, and common factor theories. For example, dialectical behavior therapy, transference-focused psychotherapy, mentalization-based treatment, schema-focused therapy, structured-clinical management, and general psychiatric management have all been shown to improve BPD symptomatology. Favorable outcomes have also been shown from stepped and dismantled manualized therapies (Choi-Kain et al., 2017). Though available and promising, many clinicians working in community settings do not have the resources necessary to administer comprehensive manualized treatments (e.g., specialized trainings, supervision, etc.), or even the knowledge of their existence—making known ways to competently treat clients with BPD profoundly lacking or inaccessible. These disconnects between research and practice may exacerbate clinicians’ apprehension or fear of treating those with BPD, maintaining biased stigma even further.

Along with being a treatable disorder, BPD also has a high rate of remittance of ~25% within a year, ~50% within 2 years, and up to 93% over a 10-year period. Once those with BPD have successfully remitted, they show very low rates of reoccurrence or relapse of around 6% (Gunderson et al., 2011; Gunderson & Palmer, 2012; Zanarini et al., 2005; Zanarini et al., 2010). While clients with BPD present in various way that can be complicated, the majority of those in treatment do not require constant availability of clinicians and are actively seeking to relieve their painful emotional worlds. As therapists often experience those with BPD as “resisting treatment,” such wariness or felt hostility is better understood as a symptom of the disorder, or an example of transference, and not a personal attack on the therapist (Gunderson & Palmer, 2012).

Research studying personality disorders is often overlooked and underfunded. Randomized control trials (RCTs) examining successful treatments for BPD are overwhelmingly scarce, making up only 7% of all psychotherapy process RCTs, despite having up to a 20% prevalence in clinical populations. Comparatively, RCTs focusing on depression and/or anxiety, for example, make up 83% of trials yet hold a global prevalence of 55%. Though one of the costliest disorders to health care systems, as those with BPD utilize several services like psychiatric hospitalization, individual and group therapy, day treatments, and recovery house residences, BPD remains notably under researched (S. McMain, personal communication, July 6, 2022; Soeteman et al., 2008).

Fostering Alliance with Borderline Personality Disorder Clients

As with most clinical cases, therapeutic alliance serves as a top predicator of successful treatment outcomes for those with BPD and should be thought of as an integral focal point of any treatment regardless of orientation (Barnicot et al., 2012). Ways of building therapeutic alliance can include providing psychoeducation about the disorder, taking client’s’ emotional reactions of events/interpersonal struggles seriously, and creating goals together. In fact, even just the disclosure of a BPD diagnosis to a client can contribute to a stronger alliance, as doing so can increase collaboration between the dyad, lessen feelings of aloneness, and further understanding of the disorder, helping to manage a client’s expectations of emotional experiences (Bateman & Fonagy, 2016; Gunderson & Palmer, 2012; Lequesne & Hersh, 2004). Though clinicians often describe challenging feelings of countertransference while working with BPD, research has shown that a client’s own burnout from treatments is a top predictor of clinician burnout. This, again, suggests that thoughtful and successful treatment early on, including working towards a strong alliance, are essential when treating these individuals (Linehan, 2000).

Summary of Shame and Stigma of Borderline Personality Disorder

BPD is a disorder that constitutes a large portion of a clinical population. Contrary to popular myths, studies indicate that BPD has a better prognosis than other serious mental illnesses (Lieb et al., 2004). Though symptoms of BPD typically consist throughout the lifespan, they can largely decrease with time and treatment. Research has shown that the prognosis of BPD is characterized by high rates of remission and low rates of relapse, with fostering a strong therapeutic alliance and providing psychoeducation being key aspects of any treatment. Though the prevalence of BPD is notable, trials studying effective treatment of such are lacking.

Mitigating stigma by having open discussions about BPD can help reduce misconceptions and encourage clinicians to be more compassionate toward these individuals. An essential part of reducing clinicians’ difficult countertransference feelings towards those with BPD is recognizing behaviors that engender such feelings as symptoms of the disorder, and not personal attacks to the therapist. Increasing awareness that BPD is a treatable mental health concern can lessen stigma and judgement of these individuals, decrease therapists’ apprehension and anxiety towards treatment, and cultivate, as Marsha Linehan says, “a life worth living” for those with BPD.

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Carla Capone, MS

Carla is a 5th year clinical psychology PsyD student at Chestnut Hill College in Philadelphia, PA. Her clinical and research interests center around psychotherapy process and understanding effective treatments for borderline personality disorder.