Reducing Stigma of Borderline Personality Disorder

Mental illness (MI) has been viewed negatively long before the official labels existed. The abuse inflicted as treatment in asylums, less than 50 years ago, reinforced the public's views about people with MI needing to be locked up away from society and physical rehabilitated to be 'normal'. This negative view becomes attached to the label of mental illness and becomes stigma.

Stigma is an indicator of shame which separates people from the general public or society. The stigma demonstrates the discrimination and prejudice society holds toward people with mental illness. Stigma affects the person with mental illness, as well as their supporters, and the access to services and resources in the community. Stigma is frequently associated with Borderline Personality Disorder (BPD): a serious mental illness characterized by American Psychological Association (2013) as having continuous fluctuations in personal relationships, self view, and emotions that make it difficult to manage and cope with at times. It is also evident that people with BPD have reckless and/or 'manipulative' behaviours in different settings: substance abuse, spending, self-harm, risky sexual behaviour, etc. 

For more general information about Borderline Personality Disorder: 

            A review study by Daniel Ring and Sharon Lawn (2019) examined the stigma surrounding BPD from the perspectives of mental health professionals (MHP) and people with the diagnosis. People with BPD are viewed by MHP as being more in control of their behaviour than other mental illnesses and are often seen as non-compliant, attention seeking, and manipulative in the treatment process. The view that people with BPD are in control of their symptoms reduces empathy for those with the condition. This belief is a barrier to understanding the condition and how to manage it for both people with BPD and MHP.  

From the perspectives of people with BPD, the label was seen to produce negative reactions and feelings from others as some people believe BPD is not a ‘real’ mental illness. People with the label also avoided seeking help because the fear of stigma and feeling as though their thoughts and concerns were not addressed. Both parties also emphasize the need for more specialized services as MHP do not feel they are adequately trained to provide services to people with BPD and there is a high demand for services for people with BPD.

MHP often believe people with BPD are not treatable and avoid providing treatment because it is not their responsibility to do so. Also, MHP having a fear of death was associated with negative attitudes toward people with BPD. MHP avoid giving and disclosing the BPD label to protect patients from the stigma which reinforces it. One study reported that only 9% of clinician told patients their BPD diagnosis directly and strategies to conceal the BPD diagnosis are justified to avoid the label and stigma. However, the BPD label itself had a positive influence on people by explaining their symptoms and allowing the person to separate their symptoms from themselves.  The problem with these stigma perspectives of BPD is that it decreases the likelihood to seek help or continue seeking help; consequently, worsening the persons’ symptoms and declining the ability to gain social support and care as a result of the isolation.

Stigma is a barrier to accessing quality mental health services for people with mental illness especially for people with BPD, as they are seen as treatment resistant and manipulative patients.  It is essential to learn and teach about the stigma people with BPD encounter at the treatment level to improve help seeking behaviour. Borderline personality disorder affects 5.4% of Canadians (Statistic Canada, 2015). People with BPD often partake in self injurious behaviours and are at an increased risk of suicide, as 8-10% of people with BPD die by suicide (American Psychological Association, 2013). Also in Canada, suicide is the second leading cause of death for people age 15-34 (Government of Canada, 2019). BPD stigma awareness and education for mental health practitioners is a starting point to improve treatment outcomes.  

To reduce and educate MHP on BPD stigma a framework was proposed by Ring and Lawn (2019) to understand stigma and BPD in healthcare settings. The model considers the perspectives of stigma from people with BPD and MHP to look at the relationship and situation stigma occurs. The framework illustrates a cycle of stigma that would be helpful in BPD education programs as it demonstrates the stigma interaction between MHP and people with BPD that fuels the stigma:  

Educational programs on BPD are important to reduce the stigma at the treatment level and improve the skills working with people with BPD. Addressing the stigma is essential to improve help seeking behaviours and treatment outcomes. Majority of MHP wanted and were willing to participate in workshops or training on BPD. The educational programs should emphasize improving empathy toward people with BPD to reduce stigma and fear of BPD. The best treatment results occur when the patient is treated like a person and when the MHP is honest with the patient. BPD education for MHP has shown improvements in attitudes about people with BPD.

More research is needed to implement and test the effectiveness of BPD educational programs. To reduce the stigma surrounding BPD some studies suggested the use of an interaction based anti-stigma workshop that includes people with BPD talking about their perspectives. The first-person accounts were seen as useful to address some of the stigmatizing views from MHP. Another suggestion was to encourage people with BPD to share their stories to break down the stereotypes and stigma attached to the label.

References

Ring, D., & Lawn, S. (2019). Stigma perpetuation at the interface of mental health care: A review to compare patient and clinician perspectives of stigma and borderline personality disorder. Journal of Mental Health (Abingdon, England), 1-21. doi:10.1080/09638237.2019.1581337

American Psychological Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). Washington: American Psychiatric Publishing.

Government of Canada. (2019). Suicide in Canada: key statistics (infographic). Retrieved from https://www.canada.ca/en/public-health/services/publications/healthy-living/suicide-canada-key-statistics-infographic.html

Statistics Canada. (2015). Health state descriptions for Canadians: Mental illnesses: section f personality disorders. Statistics Canada Catalogue no. 81-619-M. Ottawa. Version updated November 2015. Retrieved from https://www150.statcan.gc.ca/n1/pub/82-619-m/2012004/sections/sectionf-eng.htm

BPD Info-graphic:https://i1.wp.com/i.pinimg.com/originals/6d/d7/6c/6dd76c3a484770060ab2a251dc07bba4.jpg?ssl=1