[Content Warning: CSA, sexual assault, rape, psychiatric abuse, racism, homophobia, suicide]
(22 minute read: The reference section adds 7 minutes to the read time)
It is currently Borderline Personality Disorder Awareness month, and as I am growing steadily more sick of the entire concept of BPD, I have decided to raise some awareness of my own. My personality was recently awarded the title of disordered, after I submitted a formal complaint about my psychiatrist, in which I detailed a number of failures in my care, including failure to follow Trust policy and NICE guidelines, several breaches of the NHS constitution, and willful ignorance of the Mental Capacity Act 2005. Apparently, the length and complexity of patient complaints is how psychiatry decides on diagnoses these days.
I am going to use this blog to (among other things) highlight the reasons why I believe BPD is an invalid diagnosis, how it harms those it labels, and my general feelings about psychiatry (which at the moment are not very forgiving).
Borderline Personality Disorder (BPD) (1), also known as Emotionally Unstable Personality Disorder – Borderline type (2), is without a doubt one of the most controversial and disputed psychiatric “diagnoses” of the modern age (3,4). The label has been described as the “virus of psychiatry”(5), a “wastebasket diagnosis”(6), “the kiss of death”(7), and is considered by many service users to be synonymous with being blacklisted (8). Once diagnosed with the disorder, many people find themselves discharged from mental health services, signposted to other services, or barred from accessing specific mental health services altogether (9,10). If and when BPD patients do have contact with either physical or mental health care services, they frequently face pejorative and abusive attitudes from staff (11,12,13,14,15,16) are often considered to be less unwell than other patients (17), are less likely to be believed when they report ill health or distress (18), and sometimes even end up being arrested and prosecuted for attempting suicide, or for calling the emergency services when suicidal (19,20).
The majority of people who receive the diagnosis are young women (often victims of childhood sexual, physical, or emotional abuse (21)) who are said to display “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity.” (22)
BPD is highly stigmatised within and by the medical field with many clinicians reporting that they view BPD patients as “manipulative”, “difficult”, “abusive”, “demanding”, “attention-seeking”, “non-compliant”, and “disruptive”(23,24,25,26,27,28). Some studies go as far as suggesting that the emergence of the personality disorder diagnosis was a deliberate effort to group “difficult” patients together (29); with the categorisation of personality disorder acting as a “useful smokescreen for detaining difficult people” (30). Critics of the diagnosis remark upon its apparent lack of scientific validity and credibility, the value judgements and moral statements that it’s diagnostic criteria rely entirely upon, and its gendered, inconsistent, and punitive application (31,32,33,34,35); with many patients reporting that they only received the diagnosis after making a complaint about their care provider.
As I previously mentioned, I have personally experienced such a situation myself, having had my personality pathologised by my psychiatrist a week after I made a complaint - about my psychiatrist. I absolutely do not believe that this was any sort of coincidence. I have been under the care of my local mental health services for five years and have had a number of different lead professionals consider my difficulties to be related to PTSD. One week after submitting a formal complaint about my care under the psychiatrist, I was given one of the most toxic, stigmatising labels that a person could ever receive in medicine. The credibility of my complaint is now being questioned, as my psychiatrist has (kindly) suggested that this “inability to properly engage” with services is merely a manifestation of my apparently disordered personality – not his clinical negligence and incompetence.
Before submitting my complaint, I was aware that many people in the same situation I was in had their diagnoses changed to BPD following a complaint. So, I was not completely taken aback by the sudden change in my notes, but I was surprised at both the exceptionally brazen nature of the diagnostic application, and the speed of it.
I have been critical of BPD for a number of years now, as a medical student, a mental health worker, a mental health service user, and a carer. I have also been very aware that with my psychiatric presentation (a young woman with a history of childhood abuse, who occasionally engages in self harm) I would most likely come across a clinician at some point who wanted to diagnose me with BPD. I have comforted myself for a long time with the thought that I don’t fit a large number of diagnostic criteria. I do not have “chaotic personal relationships” or “mood swings”, I do not have a “fear of abandonment” or an “unstable self-image”, I am not “reckless”, “paranoid”, or “angry” … I fit one, maybe two of the nine diagnostic criteria. Phew, I have thought a number of times, thank goodness for that …
It wasn’t until recently that I thought about the ramifications of comforting myself in this manner. By using the diagnostic criteria to decide I did not have the disorder, I was actually acknowledging the validity of the diagnosis – in essence, throwing other people under the big BPD bus, to protect myself. When thinking about the diagnosis being applied to me, I wasn’t thinking “the diagnosis does not hold scientific validity, therefore I do not recognise it”, I was thinking “I’m not like those other people they are describing”. But really, I am. I am those other people because I have been punished by psychiatry with a bullshit diagnosis that does not describe me, does not help me, does not represent me, and does not give any meaning to my life. I am not like those other people because we share “BPD symptoms”, I am like those other people because we have all been failed by mental health services; punished for our distress, or for asserting our right to stand up for ourselves, or for being a woman who has attempted suicide, or for being a woman who conforms to gender stereotypes, or for being a woman who doesn’t conform to gender stereotypes, or for having a member of staff dislike us, or for being an undiagnosed autistic person, or for asking for help more than once (36,37,38)..
I am a young woman who has been through extreme childhood trauma, trying to make it through life, while navigating the immense amount damage done to both my body and my soul… and I refuse to be pathologised by the abusive, patriarchal, ableist, racist, homophobic, misogynistic, power hungry entity called psychiatry.
I enjoy writing, I can’t resist banging out a good literature review, and I am finding this non-formal method of expressing myself oddly freeing compared to the usual style I have to submit for university… so, I’ve decided to start this blog to join the many others who have come before me writing about BPD – to lay out why it’s a bullshit diagnosis, describe how much damage it causes, and has caused, and express my desire for its end. Hopefully one day BPD will end up in the bin where it belongs, right next to other bullshit “mental illnesses” like Hysteria, Drapetomania, and Homosexuality.
So, where to begin… Well, I don’t think it’s possible to discuss mental health without first laying out what the current definition of mental illness actually is (seems like it would be easy to define – but when your girlfriend is a philosophy and medical ethics student, you discover that what you once thought was a simple concept, is actually mind-bendingly confusing) . When describing thoughts, feelings, and behaviours that are healthy vs. pathological, one first has to consider what healthy thoughts, feelings, and behaviours are. Despite the fact that the description and categorisation of mental ill health forms the very foundation of psychiatry, the terms mental “healthiness” and “unhealthiness” do not actually have clear, or unanimous definitions. There is an enormous amount of medical, psycho-social, and philosophical literature on the topic (which I am barely going to scratch the surface of, because no one is marking this); with a long-held argument over the ideas of social constructivism, vs radical objectivism (39). Theories include biological definitions, where unhealthiness is described as a physiological deviation from the ‘natural state’ of the organism (40); normative approaches that consider mental ill health to be a ‘divergence from social norms’, requiring a shared judgement about our collective values (41,42); and hybrid theories which consider aspects from both biological and normative arguments to be involved in the concept of mental illness, for example, Wakefield’s hybrid theory, which posits that a psychiatric condition could be considered as such, if it causes harm to the individual, and results from a failure of an internal mechanism to perform its function (43).
The DSM, despite recognising that “no definition adequately specifies precise boundaries for the concept of ‘mental disorder’” (44), gives a brief explanation of how it recommends distinguishing normal from pathological behaviours:
“The boundaries between normality and pathology vary across cultures for specific types of behaviours. Thresholds of tolerance for specific symptoms or behaviours differ across cultures, social settings, and families. Hence, the level at which an experience becomes problematic or pathological will differ. The judgment that a given behaviour is abnormal and requires clinical attention depends on cultural norms that are internalized by the individual and applied by others around them, including family members and clinicians (45).”
This definition seems to display a normative approach, considering pathological thoughts, feelings and behaviours to be defined as such by a deviation from cultural understandings of what is and is not normal or acceptable within that culture. (This indicates that in one culture a person may be viewed as healthy and normal when displaying a certain behaviour, while in another, the person displaying exactly the same behaviour may be considered diseased – a concept that I find utterly bizarre when compared to physical medicine. It’s not like a giant cancerous tumour ceases to exist when the person growing it jumps on an easyJet to Magaluf). The fact that deviation from social norms can be classed as pathological in nature, is both bewildering, and frightening to me. We are so fixed in our understanding of what is normal that we actually feel it acceptable to pathologise others for not adhering to the same idea of normal – and despite recognising that this deviation is based on a social and moral understanding of normativity, we choose to correct such a deviation with medical means.
The concept of psychiatry, and ‘mental illness’ are left open to severe criticism when discussing the theoretical framework for the definition of health and ill health. Psychiatric diagnoses are normative value judgements, made by clinicians, who view a patient’s behaviour through their own lens of social understanding. Is it possible for a white, middle class man to understand the social background of a working class, BAME, woman, who has experienced years of social deprivation and childhood abuse? Is a psychiatric diagnosis, in fact, merely a reflection of the values and social standing of the individual giving it? It could be argued that by taking a closer look at the specific social situation that an individual has been brought up in and modelled themselves against, rather than comparing all people to a standard idea of normativity, the “deviation from social norms” definition of mental illness would actually discount a large proportion of those diagnosed with disorders such as BPD, as their thoughts, feelings and behaviours would be ‘normal’ in the context of their social background.
I struggle to believe that my psychiatrist: a well-educated, able-bodied, middle aged, straight, married, Christian man could comprehend my social background; a working class, autistic, lesbian, abuse-surviving, school drop out, who lived on the street for four years as a teenager and clawed her way into university by taking night classes while working minimum wage “unskilled” jobs to pay the bills. In my complaint about the poor care I received from my psychiatrist I detailed an occasion where he revealed that he had lied to me. I stated that because of this, I no longer felt I could trust him, and that our therapeutic relationship had broken down. The response to this was that I have a ‘pathological distrust of men’. (Seriously, you couldn’t make this shit up). I can truly believe that in my psychiatrist’s world, not trusting a well-respected, white male is a completely alien concept. It isn’t for me though. I do not have the luxury; I do not have the privilege of being able to trust implicitly. This is not pathological but a hard-learned lesson. One which many of us have had burned into them.
We are not born with instruction manuals on how to cope with the challenges that life dishes out. We learn by example from the environment that surrounds us; by making mistakes and being corrected; by consuming media; by watching the behaviour of our parents, our friends, our community. This type of day to day learning creates a hierarchy within society of those who are most and least likely to be considered to have a disordered way of being. While psychiatry recognises that different cultures have different behavioural expectations, and takes this into account when considering healthy and unhealthy behaviour, it does not recognise or acknowledge the same for other social groups, such as people with a lower socio-economic status – and the way it considers gender roles is madder than me.
The Catch-22 of Mental Health in Women
The “Catch-22” of female mental health (which blew my mind when I first discovered it) has been described by a number of authors (Kaplan, Busfield, Kimball, etc) (46,47) and is particularly relevant with diagnoses such as personality disorders, which are highly gendered.
Broverman, et al., used gender stereotypes to examine mental health clinicians’ criteria for healthy thoughts, feelings, and behaviours in adult populations (48) (gender is a prominent category for measuring apparent “healthiness”, as it is one of the main factors that determines societies behavioural expectations of individuals – touching almost every aspect of daily life (49)). The study recorded the conceptions of female mental healthiness, male mental healthiness, and general adult mental healthiness. Interestingly, while male healthiness aligned with general adult healthiness, women’s healthiness did not (50). This means that to be a healthy adult in the eyes of mental health clinicians, a woman must not conform to female gender stereotypes. However, if the woman deviates from female gender stereotypes to become a healthy adult, she is no longer considered to meet the criteria for being a healthy woman. (Shocking, right? It’s hardly surprising that so many women end up being diagnosed as mentally disordered when you realise this is how that diagnosis is formulated.)
“healthy women differ from healthy men [and thus healthy adults] by being more submissive, less independent, less adventurous, more easily influenced, less aggressive, less competitive, more excitable in minor crises, having their feelings more easily hurt, being more emotional, more conceited about their appearance, less objective, and disliking math and science,”
While men may be pathologised for acting in a feminine manner, women can be pathologised no matter how they act. (This punishment of typically feminine roles in men is also worth noting, because this is a situation where the devaluation of femininity hurts people other than women. As I am often reminded when talking about BPD; 25% of those diagnosed are men. In my view, this does not detract from the main issue of sexism, but strengthens it. The underlying misogyny in this diagnosis is so strong that it also punishes men for acting in a feminine manner.)
It seems to me that by basing its idea of healthy and unhealthy behaviours on social norms, psychiatry is aligning itself with the inherently unequal system of social stratification; in which people are divided into social “ranks” of importance, and acceptable thoughts and behaviours are dictated by those in positions of power, privilege, and wealth. To pathologise, and thus stigmatise, those who push back against oppressive social expectations, is to actively punish the disadvantaged and less privileged for ‘stepping out of line’. This is the context in which I view Borderline Personality Disorder.
Psychiatry and current psychiatric diagnoses are based on the moral, social, and legal norms of the wider society. As our understanding of social issues and morality changes, this change can be seen reflected in the understanding of what is and is not pathological behaviour. For example, in 1952 the DSM was first published, and listed homosexuality as a “Sociopathic Personality Disturbance”(51).
Culturally, we were shifting from the categorisation of deviant behaviour as religious in nature (e.g. demonic possession, sodomy etc) to scientific (e.g. insanity, homosexuality etc.) (52) As society was opposed to homosexuality at this time, and felt it to be an immoral form of sexual deviance, psychiatry was free to pathologise homosexuals, because they were performing a behaviour that was not culturally appropriate. Our understanding of being gay, lesbian, or bisexual now, is that these are normal (awesome) variations in human sexual orientation – but at the time, as it was not socially acceptable to be a raging bender and strut down Canal Street in a leather corset, this variation could be classed as a disorder. I think it’s extremely important to remember that when homosexuality was removed from the DSM as a diagnosable mental illness, the behaviour of gay people did not change, the nature of homosexuality did not change, what changed was the social acceptability of such behaviour. To me, this shows how exceptionally dangerous psychiatry is to those who do not meet societies expectations (probably most prominently illustrated by the classification of political dissidents in Nazi Germany, and the Soviet Union as mentally ill, so that they could be removed from society, discredited, and in some cases, murdered (53,54).) It wasn’t until the mid-1970’s that the DSM-III finally removed homosexuality as a mental illness (under much protest from psychiatrists, I might add) but by this time psychiatry was responsible for the detention, abuse, and torture of thousands of gay men, bisexuals and lesbians in the name of psychiatric treatment. These “treatments” for homosexuality included; chemical castration, electroconvulsive therapy, lobotomies, shock treatments administered though electrodes implanted in the brain, forced sexual activity with prostitutes while under the effects of hypnotherapy, genital shocks, aversion therapy which included the administration of chemical emetics/electric shocks while the “patient” viewed pornographic material, “treatment” with LSD, insulin comas, and even testicle removal from gay men, with testicles transplanted into them from heterosexual men (55,56,57,58). *Many gay men, bisexuals, and lesbians attempted suicide, or died by suicide following these “treatments” (*could the high rate of ‘BPD’ suicides be a similar phenomenon? Something to think on). It was not until 2017 that the Royal College of Psychiatrists finally issued an apology to the LGBT community, acknowledging the harm they had caused by classifying homosexuality as a mental illness, and “treating” those who they felt were inflicted with it (59) (in my opinion, far too little, far too late).
This is interesting though, as technically, by using a normative approach, psychiatry was not “wrong” to categorise homosexuality as a mental illness. Psychiatry bases the definition of mental healthiness/unhealthiness on social norms and uses this definition to categorise all mental illnesses. Society felt that homosexuality was immoral and deviant, and this was reflected in psychiatry. The fact that (some of) society has (kind of) changed its mind on LGBT+ is irrelevant – by using normative value judgements, not only do we make (and continue to make) these mistakes, but we also remove the ability to make retrospective judgements about the validity of historic mental illness diagnoses (60).
Another diagnosis to mention is drapetomania. During the 1800s, enslaved African men, women, and children in America were diagnosed with mental illness when they ran away from their slave masters (a condition called drapetomania - literally meaning “mad runaway slave” (61)). Slavery was considered the “natural state” of Africans, with freedom causing misery. Any behaviour that sought freedom was considered pathological (62) - why would a healthy person seek misery? We now look at this in the context of our current social understanding of the morality of slavery and are (hopefully) horror struck.
I feel that this is a perfect example of the deeply flawed nature of psychiatric diagnoses. As we are continuously evolving and our understanding of ethics and behavioural “deviations” growing, we will forever look back on what we once classed as mental illness with shame; but, unless we fundamentally change how we view deviations in terms of mental illness today, we validate the process that made such huge human rights abuses possible in the first place.
I believe that by both understanding social norms (including, why they are constructed, who stands to benefit from them being maintained, and how this interacts with psychiatric diagnosis), and by ensuring that we do not dismiss diagnoses such as homosexuality and drapetomania as mere erroneous classifications, a clear picture of what mental health care is doing wrong can come to light. The latter is of particular importance. If we allow psychiatry to classify diagnoses such as homosexuality as ‘errors in judgement’, we are complicit in the continuation of normative judgements in its diagnostic process. We must recognise that under the current definition of mental illness, homosexuality was correctly identified as pathological – and that the real error in judgement is the diagnostic process itself; only then can we be truly critical of diagnoses such as BPD.
The concept of pathologising socially deviant thoughts and behaviours is deeply political in nature. Homosexuality was pathologised against the backdrop of society’s extreme homophobia; if being gay was a sickness, prejudice was legitimate, and stamping it out, a kindness. The concept of drapetomania was based entirely upon the racist and white supremacist notions held by most of the western world. African people were ‘supposed’ to be slaves, this is how slavery was acceptable. If slaves were trying to escape their captors, it was because they were mentally ill, not because they were desperately seeking freedom... in the same fashion, Borderline Personality Disorder only makes sense in a society that oppresses and subjugates women, and a society that makes every effort to deny and minimise child abuse, and sexual violence.
Are Personality Disorders Caused or Constructed by Society?
“…misogyny makes women mad [...] through depriving women of power, privilege and independence. Or misogyny causes us to be named as mad. It dismisses witches, wise women, suffragettes and battered women as mad. Labelling us mad silences our voices. We can be ignored. The rantings of mad women are irrelevant. Her anger is impotent.”(63) – Jane Ussher, 1991
In reading many feminist perspectives on mental illness there seems to be a common theme of theories that either agree with the existence of mental illness as a concept, but attribute the experience of this type of emotional distress to living in an oppressive patriarchal society and the daily traumas faced by those who lack power and privilege; or believe “mental illness” was created as a concept to name the powerless as mad, thus removing their credibility and the ability for them to speak out about their oppression and trauma (64). I believe both to be true. This ‘dual approach’ is outlined by Shaw and Proctor in their 2005 critique of Borderline Personality Disorder (65) (it’s one of those pieces of work where you savour every single word – I would definitely recommend reading it). It’s this combination of both actual distress (in my case, caused by childhood trauma), and the pathologising of (normal) behaviour that is considered deviant in a woman (for me, being assertive in the complaint about my psychiatrist) that I believe leaves women vulnerable to being diagnosed as mentally ill – particularly with ‘disorders’ such as BPD.
Women, Abuse, Madness
Fear and hatred of women can be seen documented throughout much of human history – existing within most cultures, mythologies, religions, and philosophies. Women are the ultimate dichotomy; simultaneously the bringer and bearer of life, but the route of all evil; powerful and powerless; pure and sexually deviant; to be worshipped and degraded; madonnas and whores. As Ussher asks, ‘is it surprising that we are made mad?’(66).
The subject of women and madness is vast, and I certainly cannot do it justice in a blog post. At the heart of the subject is the intrenched misogyny that built and continues to shape our society; the topic of which is certainly far too long a history to delve into here. I will do my best to concisely illustrate what I mean.
Since people first began recording human history, we can see that society has consistently categorised women as separate and lesser to men, and within this separate group, further negatively categorised women who do not conform to cultural gender expectations (67). Women have been considered too weak to resist the temptation of an apple, or the lure of a closed box, unleashing evil upon humanity; susceptible to the outside forces of demons and magic, bringing disease, madness, and misfortune to our communities (68); prone to unnatural behaviours due to the biology of our “wandering wombs” or “defects” in our souls (69); naturally inclined to be fantasists, unable to tell fact from fiction when recalling “invented” childhood sexual abuse (70); the feeble minded, weaker sex (71) in need of “liberation” through lobotomies, ECT, and insulin comas (72); either nymphomaniacs or frigid when over or under displaying “normal” levels of sexual desire (73); and finally, today, unworthy of care because of our disordered, angry, demanding, irrational, volatile personalities.
BPD is the latest in a long line of “explanations” of women’s behaviour, used to silence and castigate us when we do not fulfil societies expectations. By failing to recognise gender power dynamics, and ignoring the history of societal oppression of women, psychiatry acts as a form of social control; pathologising normal behaviour so that it can be “treated” until it conforms. Moving on from the social construction of Borderline Personality Disorder to the social causation of distress, this type of control is mirrored. Treatment for BPD exists not as a panacea for the distress caused by childhood abuse and sexual violence, but as a means of containing the distress, so that other people do not have to witness it or acknowledge its source (74).
As almost all research and documentation about Borderline Personality Disorder acknowledges, a large proportion of the people who receive the diagnosis have a history of trauma (75,76,77). The percentage varies across studies (78,79,80,81,82) with one recording that as many as 91.6% of people with a diagnosis of BPD report experiencing trauma (83). This includes incest (75%), sexual abuse before the age of 16 (86%), physical abuse (71%), witnessing serious domestic violence (62%) and witnessing sexual abuse (13.3%) (84,85). Overall, people with a diagnosis of BPD are over 13 times more likely to have experienced childhood adversity than individuals in non-clinical controls (86).
I would expect any reasonable person looking at these figures to reach the conclusion that childhood trauma is of significant aetiological importance when describing the type of distress that is so often classed as personality disorder. This is not the case, however, as despite the continuing research into trauma and BPD, psychiatry refuses to acknowledge trauma as anything more than a risk factor. This could be attributed, again, to the reflection of social values. We have created a society that does not wish to acknowledge the extent of childhood abuse and sexual violence, so we cover it up socially by ignoring victims, and engaging in victim blaming; legally, by making it difficult for victims to pursue prosecution of the perpetrator; and medically by pathologising the emotional effects and determining them to be ‘intrinsic to personality’.
As I have previously stated, psychiatric practice reflects societal values, but I do not believe that psychiatry can be so easily excused as merely a mirror for the wrongdoings of society. Psychiatry is, and has always been, an active participant in the subjugation of vulnerable, abused, and misunderstood people. These diagnoses (current and historical) are not accidents or scientific errors, but part of a wider system of social control. Psychiatry is not a symptom of racism, homophobia, or misogyny, but a tool often wielded by those who wish to maintain these systems of oppression.
Survivors who come forward suffering from the immense psychological after-effects of their abuse are told they are the problem; their personality – the very essence of their being – is disordered, pathological. Someone chose to abuse them, to commit an unspeakable act of violence and hatred against them, and yet, they are the one considered sick. After first acknowledging how ridiculously fucked up that is, it’s important to recognise the political nature of silencing this particular demographic.
Physical and sexual violence against women is an everyday occurrence, on an inordinate level. Worldwide, the WHO reports that 1 in 3 women have experienced physical and/or sexual violence by an intimate partner or non-partner sexual violence (87). 59% of young women report at least one unwanted sexual experience (e.g. being flashed, groped, attempted rape/sexual assault, actual rape/sexual assault) before they are 18 years old, with almost one third of these incidents occurring before they were 12 years old (88). And yet, despite its prevalence, sexual violence remains drastically underreported (more than 3 out of every 4 sexual assaults are not reported (89)), and under prosecuted (only 1.7% of reported rapes in the UK were prosecuted in 2018 (90)).
A 2005 study by Amnesty International looked at people’s perceptions of the extent of sexual violence and rates of prosecution. The results showed that the majority of respondents felt the extent of sexual violence was at least five times lower than reported figures, and the prosecution rates up to five times higher (91). Disturbingly, a large proportion of those surveyed blamed the victims for their own assault:
· 26% of those asked said that they thought a woman was partially or totally responsible for being raped if she was wearing sexy or revealing clothing
· 30% said that a woman was partially or totally responsible for being raped if she was drunk
· 22% of those asked said that they thought a woman was partially or totally responsible for being raped if she'd had many sexual partners
The perpetuation of these types of “rape myths” through film, news media, social media, and through professionals who work with perpetrators and victims of sexual violence (e.g. Police, judicial systems, mental health workers, social workers etc) serves to create a false narrative; denying/minimising the effect it has on the victim and blaming the victim for their own victimisation (92). Reducing or denying the damage caused by sexual violence, and blaming victims for their experience protects society from having to confront reality by creating an environment that denies the extent of the problem (93).
There are many different reasons, theories, and analyses as to why society insists on denying the extent and effects of sexual violence. Personally, I believe the motives rest on a dual foundation of patriarchy (in which social systems dominated by men will aim to maintain their own interests, i.e. the subjugation and exploitation of women), and the “just-world” fallacy (whereby people suppress thoughts and feelings of fear about the unpredictability of the world, by believing in a universal force that ensures morally good actions are rewarded, and immoral actions are punished (94) – e.g. “what goes around comes around”).
In my opinion, while the individual actions of staff members who actively stigmatise patients they have labelled with BPD serve to “other” those with the diagnosis – removing the possibility that the staff are at all vulnerable to the traumas and distress experienced by those with the label - the institution of psychiatry falls into the category of maintaining the interests of the patriarchy by denying, obscuring, and minimising the extent and devastating effect of childhood abuse and sexual violence.
Psychiatry undertakes this central role in the denial of the extent of sexual violence and its normalisation in society through:
(1) Pathologising the distress caused by sexual violence (i.e. the distress displayed by this person is abnormal, and a symptom of mental illness, rather than the distress displayed by this person is a normal – nonetheless distressing - reaction to a traumatic experience)
(2) Categorising the “pathology” as being located inside the individual, rather than acknowledging and recognising the external context and aetiology (i.e. this person is distressed because they have a mental illness; the illness is causing the distress)
By pathologising the distress caused by childhood abuse and sexual violence, psychiatry effectively silences victims; misrepresents the real number of people who access mental health services for support after these experiences; and obscures the significant effect childhood abuse and sexual violence have on society. If the 91.6% of those diagnosed with BPD who have disclosed abuse were actually categorised as experiencing normal and understandable distress due to trauma, the statistics in our mental health services would look very different.
I hope one day (soon) we will sit up in some kind of collective realisation of horror, that as we have not been prepared to acknowledge the extent of child abuse and sexual violence in society, we have allowed psychiatry to punish, pathologise, and stigmatise survivors of abuse with the label borderline.. while I won’t be holding my breath, I am deeply saddened and angered by the situation many people like myself find themselves in. I was so alone as a child, faced with the heavy weight of my reality. I cannot describe the depths of the despair, the powerlessness, the guilt, and shame that I was made to feel. And although I tell myself every day that I was not responsible, that I did not do anything wrong, that child who still lives inside me cannot escape the darkness cast by my abusers. To reach out a hand and trust that the person who took it would not hurt me was the biggest achievement of my life, and it was punished by a man whose ego I bruised when I pointed out he was not following his own rules. His words are lodged firmly in my head now – distrustful, angry, paranoid, accusatory, damaged, pathological – I can feel them elbowing their way through the years of work it took to build up my self esteem to the point where I could approach my doctor, because I finally felt I deserved help. The word deserved is being rewritten by his hands; I deserved the abuse, I deserved the pain, I deserved the humiliation, I deserved the utter terror… because I am fundamentally a bad person, deep inside, my personality is at fault.
This is the everyday reality of Borderline Personality Disorder; it reinforces everything I was ever told by my abusers. It not only creeps into your head and tells you that you’re worthless, but officially labels you, openly, brazenly, for all to see. Unlike my childhood abuse, which I could hide under bravado and layers of clothes, BPD sits boldly in the open, shouting its name, writing itself over and over, crossing out everything positive anyone ever thought of me, stripping me of what little power I had reclaimed.
And so I say again, this diagnosis has to go. It is nothing more than a medically sanctioned punishment for those who break social conventions and is used to silence the most marginalised in our society. Draw together the historical systematic subjugation and oppression of women, and a society not willing to acknowledge the extent or effect of child abuse and sexual violence, and BPD is born. It neatly solves both problems by packaging all the dissidents, the non-conformists, the abused, and the voiceless into one box, and sealing it up without air holes. But we are not a problem that is going away any time soon, and as more and more of us are packed into this box, we will only get louder.
Wren.
References
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