Is It Valid to Call the Personalities of Trauma Survivors Disordered?

This is a response to “The validity of borderline personality disorder: Robins and Guze applied” by Mark Ruffalo originally published here

Arguing against the construct validity of BPD

The question of whether borderline personality disorder (BPD) is a valid diagnostic entity can’t be settled simply by showing that a particular cluster of difficulties can be reliably identified, researched, or responded to in treatment. Reliability and clinical utility are not unique to valid constructs; history is replete with categories that could be consistently applied and acted upon, but which we would no longer regard as capturing real entities. Familiarity and institutional entrenchment are not the same thing as validity. The real question is whether the diagnosis meaningfully captures something that exists as a coherent phenomenon in the world, rather than something we have learned to see by repeatedly naming it.

When you look closely at the evidence typically offered in support of BPD’s construct validity, it is far less conclusive than is often claimed. Much of it can equally be understood as inferring there is something distinct and specific about a broad, heterogeneous set of distress responses that are highly dependent on developmental history, relationships, power, threat, and context. In other words, we may be mistaking a convenient descriptive shorthand for a discrete disorder.

The limits of Robins and Guze

Robins and Guze’s framework is frequently invoked as though it were a neutral arbiter of diagnostic reality. It isn’t. Their criteria emerged from a period in psychiatry that assumed mental disorders would eventually come to resemble medical diseases: discrete, bounded entities with clear causes and trajectories that can be objectively tested for. Fifty years on, that assumption has not been borne out—not for personality disorders, and not for most of psychiatry more broadly.

More importantly, the Robins and Guze validators primarily assess internal coherence within an existing diagnostic system. They tell us whether a category behaves consistently once it has been defined, not whether the category itself is conceptually sound or necessary. A construct can show reliability, familial aggregation, apparent stability over time, and even treatment responsiveness, while still being theoretically muddled or overly inclusive. None of those features, on their own, establish that we are dealing with a specific group rather than a useful but imperfect clinical convention.

Symptom specificity and the problem of heterogeneity

One of the most persistent problems for BPD is the sheer breadth of presentations it accommodates. Two people can meet diagnostic criteria while sharing only a single feature. That alone should give us pause when we talk about a “coherent syndrome.”

The characteristics often described as central to BPD—emotional lability, interpersonal sensitivity, identity disturbance, impulsivity, fear of abandonment—are not unique to it, nor do they reliably cluster together outside the diagnostic framework itself. These features appear across trauma-related conditions, mood disorders, neurodevelopmental presentations, and in people navigating ongoing adversity.

Attempts to distinguish BPD on the basis of “reactive” mood shifts versus more episodic or endogenous mood changes rely heavily on retrospective interpretation and clinical judgement. In everyday practice, clinicians frequently struggle to differentiate BPD from bipolar spectrum conditions, PTSD and complex trauma, ADHD, autism, or chronic depression. This persistent diagnostic ambiguity suggests that discriminant validity is weaker than formal reliability studies would imply.

When statistical methods are applied, they tend to show overlap rather than clean boundaries. Where distinctions do emerge, they often map onto severity, developmental timing, or trauma exposure rather than discrete diagnostic entities. Framing cPTSD as “subsyndromal BPD” is telling here: it assumes BPD as the reference point, rather than questioning whether BPD itself is a product of a particular diagnostic lineage.  A recent example illustrates the point. In an ACAMH Learn webinar, Michael Kaess described adolescents who self-harm. Those exposed to significantly greater adversity also presented with more severe difficulties—and were the ones more likely to be labelled with BPD. To be explicit: this was not framed as a more severe response to more severe adversity, but as evidence of a different disorder.

Genetics without specificity

Heritability estimates for BPD, often cited at around 40–50%, are frequently presented as strong evidence for diagnostic validity. In reality, they tell us very little that is specific to BPD. Most psychological traits relevant here—emotional reactivity, impulsivity, negative affect, interpersonal sensitivity—show similar levels of heritability across the population.

Family and twin studies point to shared vulnerability for broad dimensions of emotional and relational difficulty, not for BPD as a distinct syndrome. To date, there are no genetic markers, polygenic risk profiles, or endophenotypes that uniquely predict BPD. The genetic evidence is transdiagnostic and fits far more comfortably with dimensional models of vulnerability than with categorical diagnoses.

Saying that BPD cannot be reduced to trauma alone is true, but unremarkable. It does not establish the existence of a discrete disorder; it simply reflects the well-established reality that human development is shaped by multiple interacting influences.

Course of illness: a problem for “personality disorder”

The commonly cited longitudinal course of BPD—substantial remission of self-harm, suicidality, and emotional instability over time—sits uneasily with its classification as a personality disorder. If the defining features remit relatively quickly for many people, what exactly is the enduring pathology supposed to be?

Ongoing difficulties in relationships and work are not unique to BPD. They are common consequences of chronic trauma, attachment disruption, social marginalisation, and long-term adversity. Interpreting improvement as evidence of validity, and persistence as confirmation of personality pathology, risks circular reasoning. Neither move resolves the deeper conceptual issue.

Neurobiology: correlation without discrimination

Neurobiological findings associated with BPD—such as heightened amygdala reactivity, frontolimbic differences, or HPA-axis dysregulation—are frequently cited as evidence that the disorder is “real.” But these patterns are not specific to BPD. They appear across PTSD, depression, anxiety disorders, dissociative conditions, and in people exposed to chronic stress without any psychiatric diagnosis.

What these findings demonstrate is that sustained emotional distress and threat leave biological traces. They do not demonstrate that BPD is a distinct neurobiological condition. Without specificity, neurobiology cannot do the conceptual work it is often asked to do here.

Treatment response does not prove the category

That there are effective treatments associated with BPD does not establish the validity of the diagnosis itself. Interventions such as DBT, MBT, schema therapy, and related approaches target processes that are clearly transdiagnostic: emotion regulation, mentalising, relational learning, and meaning-making.

These therapies are helpful because they address how people cope with intense emotional and interpersonal pain, not because they map neatly onto a discrete disorder. Their effectiveness supports the importance of these processes, not the existence of BPD as a natural kind.

Gender, power, and clinical function

Although population studies suggest similar levels of borderline traits across genders, the diagnosis continues to be applied disproportionately to women in crisis and acute settings. This is not a side issue. Diagnoses shape how distress is understood, how risk is managed, and how people are treated by systems.

Historically, BPD has often functioned as a relational diagnosis—used when distress is intense, care is difficult, or services feel under strain. That it can be applied reliably does not mean it is purely descriptive. It may also serve institutional and interpersonal functions that have little to do with identifying a discrete disorder.

Dimensional models and redundancy

Dimensional approaches don’t just “add nuance” to BPD; they raise the question of whether the category adds much explanatory value at all. When emotional dysregulation, attachment insecurity, impulsivity, identity disturbance, and trauma exposure are assessed directly, the BPD label often becomes redundant—a shorthand rather than an essential construct, but a shorthand that will bring significant disadvantage to those it is applied to.

Concerns that abandoning BPD would generate confusion echo earlier resistance to revising other problematic diagnoses. Psychiatry has revised diagnostic categories before when they were viewed as harmful and inaccurate—for example, the removal of homosexuality from diagnostic manuals. We are capable of similar shifts when the evidence and ethics demand it

Conclusion

The evidence commonly cited in support of BPD’s construct validity shows that certain patterns of emotional and interpersonal suffering are common, intelligible, and responsive to care. What it does not show is that these patterns constitute a single, coherent disorder that warrants categorical separation from trauma-related, neurodevelopmental, mood, or attachment-based formulations.

BPD is better understood as a historically contingent clinical shorthand—a map that has too often been mistaken for the territory. Substantially reframing, or retiring, the diagnosis would not erase clinical knowledge. It would allow for greater conceptual honesty, reduce circular reasoning, and bring psychiatric classification closer to what the evidence actually supports: dimensional vulnerability shaped by development, trauma, relationships, and context.

Marsha Linehan, the creator of DBT said “If you meet the criteria for Borderline personality disorder do not tell anybody.  They’ll treat you differently if you do.  And many mental health professionals will refuse to see you.”

We could adapt this advice for professionals.  “If you see someone suffering, do not tell them and the world that their personality is disordered.  You will make people who are supposed to care treat them worse, if they agree to see them at all”

People diagnosed with “Personality Disorder” should never be detained in hospital

This is a fairly bold statement, and it is based on my (potentially unfair) summary of Misdiagnosed, mismanaged, mistreated: personality disorders and the Mental Health Act, an article published this year in the BJPsych Bulletin.

To be clear from the outset: I agree with the authors on a great deal of what they say. My concern is not with the critique of coercion, risk-driven care, or defensive psychiatry. It is with the conclusion, which I worry is too unilateral and too driven by diagnosis and labelling, rather than by clinical reasoning and individual presentation.

Where I agree with the authors

The authors make very valid points about how the new Mental Health Bill is unlikely to bring meaningful change for people diagnosed with BPD/EUPD. I share very similar worries (and have written about this before. Services continue to mistake restriction and coercion for care, prioritising the anxieties of risk‑averse organisations over the wellbeing of patients.

Given the millions of pounds spent on detaining people, and the devastating costs to their lives and wellbeing, most of us want change here. Where the authors and I differ is in what that change should look like.

The article frames personality disorder through a relational lens, acknowledging the impact of early adversity and disrupted attachment. It recognises that a Mental Health Act assessment — a process where two doctors and an Approved Mental Health Professional decide whether someone should receive treatment against their will — is itself a relational encounter.

That process can replay early trauma. Someone may be forced to do something against their will, echoing experiences of coercion and control, or they may be rejected and abandoned. Either way, there is a risk of re‑enactment.

The authors also highlight how repeated crisis presentations, focused narrowly on risk, can worsen relationships with services and paradoxically increase suicide risk. They are right to point out that for many people, being locked in hospital ‘to keep them safe’ is both the beginning and the end of acute inpatient treatment.

Alongside others in this field — Joel Paris among them — they note that acute wards rarely offer evidence‑based treatment for “personality disorder”, and that people who have been forced to do things throughout their lives often react badly to being forced to do things in hospital.

None of this feels controversial. We should remember what has happened to people. We should acknowledge that inpatient environments harm some people. And we should not detain people in environments that make them worse.

The part of the Mental Health Act that keeps people trapped (the bit that matters most)

Where I think the article misses something important is in its analysis of why people with a personality disorder diagnosis remain detained for so long.

At present, people can only be discharged from involuntary detention if it is not the case that:

• they are suffering from a mental disorder of a nature or degree which makes it appropriate for them to be detained for medical treatment; or

• detention is necessary for their health or safety, or for the protection of others; or

• appropriate medical treatment is available; or

• if released, they would be likely to act in a manner dangerous to themselves or others.

This is where things unravel.

There is no medical treatment for ‘personality disorder’ in the way the Act imagines. In practice, ‘medical treatment’ becomes stretched to mean forcing someone to be safe. When coercion itself is framed as the treatment, it becomes self‑justifying: if restraint and locked doors are what keep someone alive, then restraint and locked doors are always necessary for their health and safety.

The absence of therapy — or the fact that any therapy offered is delivered under coercion and thus often worthless— no longer matters. The silver bullet that blocks discharge is the clause about likely dangerous behaviour. For people whose coping strategies involve doing dangerous things to themselves, this can mean indefinite detention.

Taken to its logical conclusion, the standard becomes absurd. Someone like Frank Bruno wanting to leave hospital to go to a boxing match would not be allowed as he’d be acting in a manner dangerous to himself.

This is the part of the Mental Health Act that traps people — and it is largely absent from the article’s analysis.

Where law and ethics really collide

The authors argue that compulsory detention of people with a personality disorder is ethically questionable because many retain decision‑making capacity, even during crises. I agree with the spirit of this, but I think the reality is messier.

The decision about when to stop someone acting on suicidal impulses is relatively straightforward when someone is cutting themselves — behaviour that may have been present for years. It is much harder when someone is standing on the wrong side of a bridge safety rail. We can take comfort in the idea that ‘they have lived a life of self‑harm’, while forgetting that ‘they do not dangle off a bridge every night’.

The article compares this with addiction, noting that we do not use the Mental Health Act to intervene when people take life‑threatening quantities of recreational drugs. That is true, but the acuity of a lifetime of addiction is not the same as the acuity of a single, imminent, potentially irreversible act.

The authors are also right — and brave — to say that suicides will happen. There are limits to how much we can control the actions and thoughts of others. This stance is practical and honest. It can also be read, by some, as a licence to give up on people.

Diagnosis-based exclusion is not person-centred care

The article concludes that compulsory detention undermines the principle of seeing the person as an individual, because it is risk‑focused and fragments identity. This is where I most strongly disagree.

There is nothing that robs people of their individuality more than responding to a diagnosis rather than to their unique presentation.

The authors argue that the Mental Health Bill should actively limit compulsory inpatient detention for people with a personality disorder diagnosis. They acknowledge that brief, informal crisis admissions to structured, personality‑disorder‑informed settings may be helpful, but argue that repeated Section 2 detentions for people with well‑established diagnoses should be legally restricted.

It is not clear how such restrictions would work. Three Section 2s in a lifetime? One per year?

They also suggest adding a clause stating that detention should be unlikely to worsen the person’s mental disorder. As written, this undermines their own argument. More broadly, I worry about the ethics of warning against admission purely on the basis of diagnosis rather than individual history and response.

Some of the people we work with are far more likely to die in hospital than in the community. We actively warn systems about this and encourage avoidance of admission at all costs. But that advice is based on a very individual understanding of someone’s history — not on a label.

Equally, we work with people for whom hospital can be helpful. I would not want them excluded from admission purely because of a diagnosis that may have been applied briefly, superficially, or in a stigmatising way.

The risk of a dog whistle

What worries me most is how easily the position ‘we don’t admit people with personality disorder’ could become a dog whistle for exclusion.

Given how casually and inconsistently the diagnosis can be applied, I would not want a ten‑minute encounter with a locum doctor — who did not enquire about trauma history — to become the basis for never protecting someone at times when they cannot protect themselves.

I also would not want two people dangling from a bridge, one taken to hospital because they are depressed, and the other left there because they have a personality disorder diagnosis.

Guidance that already exists

The article overlooks protections that are already in place.

NICE guidance for BPD is clear that home treatment and alternatives to admission should be used first, that the length and purpose of any admission should be agreed in advance, and that clinicians should consider the likely harm of admission. These are not part of the Mental Health Act, but they are clear professional standards that support clinicians who do not want to admit.

NICE also states that people with borderline personality disorder should not be excluded from any health or social care service because of their diagnosis or because they have self‑harmed.

The Royal College of Psychiatrists is similarly explicit: patients with personality disorder should not be denied mainstream services on the basis of diagnosis alone, and Tier 4 services should include both detained and informal patients.

Arguing that people with a personality disorder diagnosis should never be detained sits uneasily with what both NICE and the RCPsych describe as good practice.

What needs to change instead

Changing the Mental Health Act to exclude people diagnosed with a personality disorder diagnosis from compulsory treatment is not the answer for me.

The Act already contains the mechanisms that keep people detained — particularly the conflation of coercion with treatment and the vague, self‑perpetuating use of ‘risk’. That is where reform is needed.

The article also overlooks the impact of the privatisation of inpatient care for those with this diagnosis. Much inpatient provision for this group is now delivered by self‑declared ‘specialist’ hospitals that are financially rewarded for providing coercion. This creates a system where people are brutalised in the name of safety, with very little scrutiny of outcomes.

We need political and legal change that allows people who have learned to destroy themselves to survive to access help without being further harmed. We need services to feel confident not to detain people when we know detention increases their risk of death. That will require explicit legislation, and clear leadership from coroners, professional bodies, and politicians.

In closing

There is a huge need to improve the care we offer to survivors of abuse, whether or not we insist their personalities are disordered.

That improvement will not come from blanket exclusions.

Featured article -Misdiagnosed, mismanaged, mistreated: personality disorders and the Mental Health Act

When “Personality Disorder” literally means a Disordered Personality

The other week I was sat with a a range of people with different clinical and lived experiences of ‘personality disorder’.  As is usual, the conversation weaved around the insult inherent in the term personality disorder and the help or treatment that can often only be accessed once that label is applied.  

I think, if you wanted to begin a therapeutic relationship in the worst way possible, you’d ignore someone’s history, tell them they had a personality disorder then watch as all the stigma associated with that label is enacted upon them.  It’s because of this I make a lot of effort (campaign?) for traumatised people not to be given a personality disorder diagnosis, for staff to understand people in terms of what has happened to them and for the world to recognise how survivors of abuse are shown huge sympathy until its decided they have a personality disorder and are then blamed for all historic, current and future problems.  

When I’m fighting that good fight, it can feel positive.  Standing with and for oppressed people.  On occasion, it doesn’t feel so good.  While we were talking the other day, someone who had been given a personality disorder diagnosis talked about how a ‘disordered personality’ really fit with how they understood themselves.  It reminded me of another discussion years ago where, after I’d suggested we shouldn’t tell traumatised people their personalities are disordered, a voice rang out with “My personality IS disordered, thank you very much”. 

So then what to do?  I make an effort to ensure a lived experience voice is part of almost everything I do in work, so how to respond when a lived experience voice champions the idea of a disordered personality?

I started thinking about it a lot.  Judgemental though it is, I felt that people “shouldn’t” think of themselves as having a disordered personality.  I thought about how in the past, “Inadequate Personality Disorder” was part of our diagnostic manuals.  When it was taken out, I think there were people who missed it, because they thought an inadequate personality really summed them up.  

I thought about the history of homosexuality.  Here it is listed in the DSM II

“302: Sexual deviations

This category is for individuals whose sexual interests are directed primarily toward objects other than people of the opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances…Even though many find their practices distasteful, they remain unable to substitute normal sexual behavior for them. This diagnosis is not appropriate for individuals who perform deviant sexual acts because normal sexual objects are not available to them.

302.0 Homosexuality”  *Fascinating that same sex relationships in prison are not illness but the day you step outside a prison they are!

Once again, I can imagine that at the time when homosexuality ceased to be viewed as an illness or disease, there were people who had been diagnosed who felt that this label summed them up perfectly.  I think most of us can look into the past and agree we should never have told people that their personalities were inadequate, nor that the people they wanted to have sex with were determined by the pathology of their disease.  A change was made for the better and their opinions didn’t count.  

I genuinely think in the future we will look back aghast at how we treated survivors of abuse both in how we label understandable reactions to living through hell and with the prejudice and discrimination we knowingly unleash once “personality disorder” is written in someones notes. 

So in the same way people with lived experience might have been ‘wrong’ to oppose their sexual orientation being viewed as an illness, are people who have been told they have a personality disorder ‘wrong’ to think they have a disordered personality? 

I then got thinking of something else.  Many people I work with have self esteem so low they could mine for lithium.  They see themselves as bad, flawed, evil, selfish and cruel.  Regardless of what cruelty, indignity or neglect has been inflicted on them by others, they have had the explanation that its all their fault (literally) beaten into them.  When someone in a white coat comes along and gives you a label that confirms every single one of the worst things you’ve thought about yourself, it makes sense to me that you’d grab hold of it.  At least it’s official now.  A validation that everything you beat yourself for was true. 

The problem is that this leads me to pathologising people in exactly the same way others do.  “You only think you have a disordered personality because you are too hurt/damaged/ill(???) to see any  different”.  I then get a free pass to ignore everything I don’t agree with because I’ve been able to pop it into my “not valid argument” pile. 

I weighed up all the above and didn’t know whether to say it out loud.  I was picturing how crushed and invalidated I might feel if some professional responded to my honest opinion in that way.  In the end with a lot of caveats about not wanting to invalidate, I did say it.  It seemed to splash into the wider discussion without too many ripples but it makes me wonder for the future. 

The categorising of personality disorder is changing.  Mind have just put out their new information about Personality Disorder talking about how all the different types have gone.  I hear on the grapevine that the next `DSM wont have separate categories.  We won’t tell people they are medially a narcissist or a borderline anymore, just that they have a personality disorder.  (As if the stigma and insult lay in the prefix rather than the ‘personality disorder’ description).  At some point all the diagnostic manuals will change again and how much influence should those who feel their personality is disordered have over the changes?  Total influence horrifies me, but no influence feels wrong too.   

I have a fairly awful vision that people who are wedded to the idea of labelling natural responses to adversity as a personality disorder while ignoring the suffering that the label brings will latch on to those who feel their personality is disordered.  That the foundation that all the stigma and discrimination is built on is justified because there are people that agree their personality is disordered.   The problem is that I find this vision awful because I think I’m right and others are wrong. 

The debate will continue and people who are in no way impacted by the stigma and discrimination will continue to argue that categorising distress differently will not make a difference.  I often have very critical thoughts about organisations who only champion lived experience voices who support their narrative, but I was aware of how much I didn’t want to hear an opinion that contrasted so distinctly with my own.

I cant come up with a satisfying, line in the sand concluding paragraph here.  I’m not going to stop telling the world we shouldn’t tell people who have lived through hell their personalities are disordered.  There will be a bit of me that’s more aware of how insulting someone who believes their personality is disordered will find it if I don’t agree.  I will say that much of my training has been around challenging the negative thoughts of those who mentally eviscerate themselves.  It’s only in in the field of ‘personality disorder’ that it seems acceptable for professionals to agree with them.

As ever, all comments welcome but just as a starting point - there is not one treatment that we have for emotional dysregulation, recurrent suicidality, self harm, relationship difficulties or anything else that will only work if the patient and people around them believe they have a personality disorder.  Not one. 

*shared with the permission of the person who inspired it :-)

Mad or Bad? – The Portrayal of Mental Illness in Joker

Written when Joker first came out…I am just back from watching Joker in the cinema and thought I’d share a few ideas I had while I was watching it.  This is one of the first films I’ve gone to see with a level of professional curiosity and twitter had whet my appetite by telling me it gave the message that people with mental illness  were dangerous.

Before we start I’m going to warn you that after this paragraph, while I won’t go into detail of the plot, there are bound to be things that will spoil some elements of the film if you haven’t seen it.  I’ll add that I thought it was very good.  Gripping, well acted and with a powerful message.  Go see it to make up your own mind then have a look at how much you disagree with what I’ve written below.

** Warnings for spoilers, violence and abuse

So we’re going to take the line that was in my head when I went to the cinema about people with mental illness being dangerous.  Throughout the film there’s a few references to mental illness.  The ones that spring to mind are Arthur (Jokers name before his name is Joker)  asking for more medication because he feels terrible all of the time.  There is another reference to having stopped taking medication and two episodes of Arthur slightly losing contact with reality.  In one he imagines being recognised, understood and hugged by someone he has admired for years.  In another he imagines someone he is attracted to liking and supporting him.  There’s a reference to him having been detained in hospital with no explanation as to why.  If you got the Diagnostic and Statistical Manual out you could probably pathologise these and I’m sure the film deliberately uses them to place Arthur in the ‘mentally ill’ bracket.  What was important for me was that none of these seemed to have any impact on the violent, antisocial and sadistic behaviour that happens later in the film.

What does bring out the descent into violence is far better explained by the question “What happened to you?”.  We learn of Arthur being at least physically abused and neglected while a child.  This led to his mothers detention in a psychiatric hospital.  While there she says how he was always happy.  I got the impression that regardless of how Arthur had felt, his mother had pushed him to show happiness and joy.  Arthur has a neurological condition that means he laughs inappropriately, often when under stress.  I wasn’t sure if this had always been there or whether it was a result of brain damage from his physical abuse.  Either way, from a young age he was given the message that he was worthless and unworthy of protection – merely a thing to be tied up and beaten.  Arthur is told that others find him creepy and even without the psychological damage caused by his upbringing, we can picture how manic laughter under stress would be like painting a target on your back in school.

Fast forward 30 years and we see Arthur working as a clown.  We see him humiliated and beaten again.  We see the people who are supposed to help him abandon him and we see a number of public humiliations as he reaches out to connect with others.  He doesn’t know how to fit in.  He is given a gun by someone who hears of his first beating.  When he finds himself being powerless and beaten again, it is shocking but not surprising when he turns to violence.  The next few scenes imply that Arthur is for once experiencing something like control.   While it’s mixed with fear it’s clear that someone who seems to have had a life being hurt by either others or himself, has found a way to feel powerful.  Over the next few scenes we find Arthur struggling to work out who he is, being betrayed by the only person he thought loved him and being set up for for his most public humiliation yet.  During this time Arthur learns what many people that I have worked with have learned – that power over others can temporarily rid the body of intolerable feelings of being vulnerable and humiliated.  It seems that this is a factor in Arthur choosing not to end his life as he planned, but to attack the person who had arranged his public disgrace.  As his violence increases Arthur finds an acceptance and approval that he never experienced during his times of trying to make people happy.  Every horrific act in the film can be understood by looking at not what was wrong with him, but what happened to him.

One of the most powerful lines in the film is:

“What do you get when you cross a mentally ill loner with a society that abandons him and treats him like trash?

You get what you fucking deserve”

I’ve read criticism of this because it draws a parallel between mental illness and violence.  I’m arguing that mental illness has absolutely nothing to do with it.  None of his actions are based on any mental illness.  It would be better to swap ‘mentally ill loner’ with ‘person who has been hurt by people who should care”.  It doesn’t sound as good to the ear, but it conveys the overall message of the film better.

Time to get the red flag out and get political.  The film makes an effort to portray society as corrupt.  Nobody helps anyone else.  There is rubbish everywhere.  Vermin roam unchallenged.  The poor are dismissed and unimportant.  Those who are interested in the poor are dismissed and unimportant.  There is only interest in those who are rich.  Obviously such a society could never exist today….or maybe it could.  This film is set in America which is the ultimate embodiment of a capitalist society, where even a self confessed sexual predator can get himself elected president seemingly on the back of being a billionaire celebrity.  The gap between rich and poor is accelerating in most western societies and in a system where people are expected to be poor, powerless and humiliated day by day, it shouldn’t surprise us that people seek power in ways we do not approve of.  As of October 1st 2019 there had been at least 21 mass shootings with at least 124 dead in the USA this year alone.  Somehow this has become an acceptable part of society which although disapproved of, seemingly cannot be addressed.

There has been a lot of disquiet about Joker.  I’ve heard that it might incite violence and I think that it could.  In the same way that Catcher in the Rye and the 120 Days of Sodom were associated with horrific acts, I don’t think it’s beyond the realms of possibility that someone who was on the brink anyway could see this film and decide to ignite a similar blaze of glory.  The film even parodies the voyeuristic news coverage that inspires the next intake of mass killers.  To watch this film and worry about the response of individuals is to totally miss the point.  We need to look outside the cinema to the world around us.  If we support a society with massive inequalities, if we condemn people to poverty based on the lottery of their birth, if we leave children to be neglected, if we tell people to seek help when there is none available and all the time we push the idea that the only thing of value is money – then we will get what we deserve.  The president of the United States has told us that people who commit mass killings are mentally ill.  This film suggests it has nothing to do with mental illness and  everything to do with the products of humiliation, poverty and injustice.

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk

Why You Don't Want A Diagnosis of Borderline Personality Disorder

Who the hell am I to say this? Well, I’ve worked in mental health services for over 25 years.  The last 10 have been in services specifically for people who hurt themselves and want to die.  The people I’ve worked with have almost always had a diagnosis of Borderline Personality Disorder or emotionally unstable personality disorder as it used to be called in the UK.  There was a time that I thought the diagnosis was useful and people just needed to understand it better, now I’m convinced that it does more harm than good.

Marsha Linehan is the creator of Dialectical Behaviour Therapy.  It is probably the most researched therapy for BPD and the only named therapy in the UK NICE guidelines for BPD.  Linehan says:

“I tell my patients if you end up in the Emergency Room for a medical disorder for gods sakes do not tell them you meet criteria for Borderline Personality Disorder.  Do not tell anybody.  You’ll be treated differently and many, many mental health practitioners wont see someone who meets criteria for Borderline Personality Disorder”

I’m trying to think of another diagnosis where one of the leading experts would advise people to keep their diagnosis secret in order to avoid mistreatment from health professionals.  There can’t be many.

I was prompted to write this after I was doing some training and a clinician who worked with students in a university kept meeting people who were asking for a BPD diagnosis.  They’d seen something on Tik Tok, had a google, and they were convinced they’d found a name for the discomfort, stress and pain they were experiencing.  The pain is real, but this blog is an attempt to explain why you might not want to describe it as BPD.

Reason 1 - Mental Health Staff will Treat You Worse

The Paper “Personality Disorder: The Patients Psychiatrists Dislike was written in 1988.  I’m not aware of any other diagnosis where you could write a paper with a similar title.  The article highlighted the negative views that psychiatrists hold towards people who get this diagnosis.  While this was 40 years ago, the study was repeated and found similar results.  These negative views aren’t limited to psychiatrists.  An Australian review of stigma for around BPD said:

"the diagnostic label of ‘BPD’ elicits particular negative beliefs and emotions in psychiatric nurses"

"these beliefs extend to other staff, such as psychologists, psychiatrists and social workers"

"clinicians report having particularly negative beliefs about young people with BPD, including erroneous beliefs about trustworthiness and dangerousness, and that they are ‘bad, not ill’.

"The label of BPD does not evoke the same stigma in the general community as it does in mental health clinicians”

That last point is interesting - the stigma is higher in mental health clinicians than in the general public.  Getting the diagnosis means your friends and family should treat you the same, its only the people who are supposed to help that will think less of you.

What will this look like?

Probably the most common ideas are that people who get a personality disorder diagnosis are manipulative, attention seeking, split teams and sabotage their treatment.

Manipulation - Because of the diagnosis, people will stop believing you.  Everything you say will be questioned, from why you were 5 minutes late to whether the awful experience you described actually happened.  Jay Watts brilliantly describes this “testimonial injustice” here.

Attention Seeking - Here, every aspect of your behaviour will understood as an attempt to draw attention to you.  This will include hurting yourself, being loud, being quiet, leaving early, being first….almost anything that differers from a victorian ideal of a demure woman will immediately fit into the attention seeking box.  If you come to your appointment on roller blades, a green wig and a suit covered it glitter, attention seeking might fit.  When you are crying because of the intensity of what you’re feeling, it probably won’t.  Because you will be understood as attention seeking, rather than getting sympathy or empathy from staff, you’ll probably find they’re annoyed with you.

Splitting - People will see you in this way when you do anything that either suggests you feel warmly towards one or more members of staff or if you suggest that you find some less friendly than others.  If you have any other diagnosis people won’t take any notice but if you have this diagnosis, when you want to spend time with the person who smiles at you more than the one who scowled, this will be you splitting the team.  You are expected to have exactly the same relationship with every member of staff in exactly the same way they don’t.  If you complain about something egregious someone has done, 1 - they wont believe you (see manipulation), 2 - They will simply assume splitting is in place.  At it’s worst, this will be what people decide is happening when you ask not to be helped by someone who reminds you of people who have hurt you.

Sabotage - Almost any time you do something that doesn’t fit with the clinicians ideas of recovery and improvement, it will be assumed you’re doing it on purpose.  That thing you did yesterday that you bitterly regret - people will think you did it deliberately.  Again, they will be annoyed with you for this.

Some people think I have some expertise in this area. It’s worth saying that my undergraduate training didn’t mention personality disorder, nor did it mention that some people I worked with would want to hurt themselves and to die. I had to learn about “personality disorder” on the job from others who hadn’t had any training. I can assure you that all the above is what I was taught by my peers, and what spread myself for a good few years before I was taught differently.

Now you might have really significant difficulties in your life, but even if you had none you’re very likely to get upset and annoyed when people treat you in the way described above.  When you react to this treatment, everyone around you will be furious and all your reactions will be fitted into the boxes above, which will irritate them more.

Reason 2 - It impacts everything

The Welsh charity Platform has an archive of awful experiences people with a BPD diagnosis have gone through, but the things I repeatedly hear about are:

1 People having wounds stitched in hospital without anaesthetic,

2 All visits to the GP seen as attention seeking so serious illnesses are missed and pain relief not given

3 Immediate risk referrals are made when you become pregnant

Reason 3 - It doesn’t identify a specific problem

As you need to get 5 out of 9 criteria to get a BPD diagnosis, there are 256 different flavours.  It means that someone can have criteria 1-5 and someone else criteria 5-9.  They then have the same diagnosis, prognosis, care plan….but they only share 1 criterion.

The Royal College of Psychiatrists gives guidance on the thorough assessment required before someone is given a BPD diagnosis.  I suspect this is because how often (in my experience) the diagnosis is given based on a brief contact and gut feeling.  I generally find that to get the diagnosis you generally only have to meet 1 criteria from the diagnosis - doing something that is bad for you, and 1 separate criteria - being a woman.  An example of the free and easy way the diagnosis is given comes from Aaron Beck, the creator of CBT.  He had two therapists talking

“I’m having trouble with my patient with BPD”

“How do you know they have BPD?”

“Because I’m having trouble with them”

Far too often I see a diagnosis made based on the poor quality of the relationship the clinician has with the patient, rather than a thorough examination of peoples history and current circumstances with reference to the criteria.

Comorbidity is very high in people with a BPD diagnosis.  Almost everyone has other mental health diagnoses too.  Research shows if you meet the criteria for one personality disorder, you’re likely to meet the criteria for others too.

In some ways a BPD diagnosis is like saying “something is wrong” without being able to identify the specific thing to help with.  That means it often doesn’t lead to help that is helpful. If the point of diagnosis is to open doors to help, the diagnosis of BPD tends to shut doors and close the minds of those who would help those with other mental health difficulties.

Reason 4 - It misses specific problems

A large proportion of people who get a BPD diagnosis have had awful experiences in their lives.  It is the diagnosis most associated with childhood abuse.  History tends to be cut off when this diagnosis is made  and people find it very hard to access therapy to help manage their traumatic experiences.  While everyone I work with is given a BPD diagnosis, in reality their difficulties could frequently be better explained in terms of PTSD and Complex PTSD.  In addition, the dustbin diagnosis of BPD will contain many people who are neurodivergent. Trying to argue this once a BPD diagnosis has been given is near impossible. There is a danger that you’re seeking help because you have some trauma in your life and this diagnosis will add to that trauma rather than supporting you to address it.

Reason 5 - You will probably end up taking medication

There is nothing wrong with taking psychiatric medication.  I’ve been prescribed it myself, I’ve had some very paranoid experiences on diazepam and welcomed things to help me sleep during a stressful period of my life.  Unfortunately, there is no licensed medication for BPD.  What this means is that when high quality studies have taken place with some people taking the medication and some taking something else, the medication has never had a significantly better result than not taking it.  Despite this, people with BPD have high levels of polypharmacy - this is where multiple medications are prescribed for the same issues.

I think those are the main reasons I’d encourage people to be wary about seeking a BPD diagnosis.  Psychiatrists that I think a lot of say “I explain the diagnosis to people in a really warm and kind way and they leave really happy with it.”  I do not doubt that for a moment.  The problem is when those people come into contact with others who are not that psychiatrist.

I’m told people ask for the diagnosis, I’m sure they do.  Whether those people are fully informed about the stigma and discrimination they will experience as a result of getting that diagnosis is another question.  Well, if they read this at least they are making an informed decision.

I’m going to try to avoid getting a personality disorder diagnosis, so what should I do?

Some tips….Do tell people that you want to avoid this diagnosis.  If you’ve had horrible experiences in your life, you might feel that Complex PTSD explains your problems better, you might feel that you may be neurodivergent.  You might work with staff to find a way of describing your difficulties that doesn’t come with all the stigma.  While there are therapies for BPD few of them will only work with people who have a BPD diagnosis.  Given that the biggest indicator of whether therapy will work is the quality of the therapeutic alliance, you might even be better off finding a therapist you trust, who feels safe, who describes your difficulties in a way you agree with and who agrees with you a way to work on your difficulties that makes sense.

People can be very literal and the difficulty with having ‘personality disorder’ written next to your name is that people treat you as if your personality is disordered. 

It isn’t. 

With 100% of the people I work with, their difficulties make sense in terms of what they have lived through, what happened, what didn’t, what life has taught them about themselves, other people and the world.  You are not disordered.

There is a chance that you feel you are disordered.  You might feel your personality is black, broken and flawed.  If you find a mental health professional who helps you think that your’e right, you might be better off fleeing from them.

Lastly, and I cant emphasise this enough, if you are suffering do seek help.  Do share you difficulties, your suffering and your pain.  I am not suggesting for one moment that you don’t try to get some support or relief.  I am warning of what happens (in my experience) when a BPD label is given and giving you some information so you can make a more informed choice. Hope it helps.

(And while I often say that the stigma around BPD is higher mental health staff than in the general public, Hollie Berrigan pointed me at the Unilad story that the image above is taken from just as I was publishing this. A diagnosis associated with serial killers. Not the diagnosis most associated with childhood abuse, serial killers. Good grief.)