[Content Warning: Suicide, self-harm, physical assault, psychiatric abuse]
Please note: I do not believe “personality disorder” is a valid diagnostic construct, and stand in fierce opposition to its clinical use. Please see my position statement for further information.
Personality disorders are highly contested psychiatric diagnoses, which describe a long-standing pattern of “unusual” or “problematic” thoughts, feelings, and behaviours. There are ten distinct types of personality disorder in the DSM-5: anti-social, avoidant, borderline, dependent, histrionic, narcissistic, obsessive-compulsive, paranoid, schizoid, and schizotypal. The ICD-11 now favours a “scale” of personality disturbance: which starts with none, then moves to personality “difficulties”, and then mild/moderate/severe personality disorder. On top of this, there are a number of “qualifiers”, including detachment, disinhibition, dissociality, anankastia, negative affectivity, and finally, “borderline pattern” which consists of the DSM-5 criteria for borderline personality disorder.
Borderline personality disorder, also known as emotionally unstable personality disorder (BPD/EUPD), is a controversial and contested diagnostic construct [1-5]. It has nine diagnostic criteria, five of which must be present to be diagnosable, these include: intense and unstable relationships; inappropriate anger; mood swings; impulsive or reckless behaviour; self-harm and/or attempted suicide; fear of abandonment; unstable sense of identity; pervasive feelings of emptiness; and stress-related dissociation and/or paranoia. Given that only five of any of the nine criteria are necessary for diagnosis, there exist 256 individually diagnosable presentations of BPD. Numerous lived-experience and academic concerns have been raised about the scientific validity and reliability of BPD as a diagnostic construct; the methods by which it is diagnosed; it’s associated stigma; and the effect the label has on clinician perceptions, treatment and outcomes of patients [6-13]. There is little academic and clinical consensus regarding what BPD “is”, and how the particular cluster of experiences it describes should be categorised. It has been suggested that BPD could be a mood disorder, a neurodevelopmental disorder, a trauma disorder, a collection of misdiagnosed people, and even a diagnostic category created entirely for the purpose of side-lining so-called “difficult” patients [14-21].
BPD is predominantly diagnosed in women and as such, is heavily criticised from a feminist perspective, as being a means of pathologising women who display too many stereotypical “feminine” behaviours (dependency, passivity, displays of emotion etc) and too many stereotypical “unfeminine” behaviours (promiscuity, assertiveness, anger, etc) [22,23]. The majority of people diagnosed with BPD are also survivors of trauma, including a high prevalence of child abuse and sexual violence survivors [24,25]. There is a growing movement against the practice of diagnosing trauma survivors with BPD, given the often devastating consequences of reframing the emotional effects of trauma as a disturbance arising from within an individual's personality [26-29]. People who identify as LGBTQ+ are also overrepresented in BPD populations [30]. Concerningly, research on this phenomenon suggests that irrespective of the persons clinical presentation, clinicians may be predisposed to provide a BPD diagnosis to LGBTQ+ patients [31]. Finally, neurodivergent people, such as autistic people and those with ADHD, are frequently wrongly labelled with BPD, or other personality disorders, often due to poor recognition and understanding of how these conditions present in women and AFAB trans/non-binary people, and stigma related to neurodivergent behaviours, communication methods, and self-harm/suicidality [32-36].
Despite BPD already having a huge collection of diagnostic criteria, it also has a large number of “unofficial” criteria, which includes “manipulative” and “disruptive” behaviour; a “demanding” or “ungrateful” attitude; “attention-seeking”; “dishonesty”; and “non-compliance” [37-41]. If staff perceive these behaviours in a patient, it can lead to a diagnosis of BPD, whether the person meets the actual BPD criteria or not. Concurrently, but in reverse, someone who already has a BPD diagnosis is likely to be perceived as displaying these behaviours, whether the behaviours are present or not [42-44]. These unofficial criteria, when gathered and discussed by healthcare professionals in staff rooms/MDTs/clinical and pseudo-clinical publications/and on social media, form a thick web of BPD mythology, which subsequently informs actual patient care. This web is seemingly impervious to scientific reality. Once a BPD myth has taken hold, it makes no difference how many people speak in opposition of it; how many studies disprove it; or how many official guidelines recommend against it; it will continue to flourish.
All psychiatric diagnoses come with stigma. All people given a psychiatric diagnosis may be victim to discrimination and unpleasant attitudes from the public and healthcare professionals. BPD, however, is one of very few psychiatric diagnoses which not only allows healthcare staff to openly discriminate and voice hideously prejudiced and bigoted opinions about people labelled as such, but actually encourages staff to propagate these views and, further to that, use their prejudice to inform patient care. In many healthcare teams, staff who do not conform to discriminatory attitudes towards patients labelled with BPD are considered naïve, inexperienced, soft, easy to manipulate, and as allowing themselves to be “split” from the team. The BPD myths become clinical “truth” and demand compliance.
I am honestly so tired of hearing these myths from people who should know better. I am tired of seeing people receive abusive and traumatising “care” based on these myths. I have been severely damaged by my own experiences of how these myths informed mine, and my relatives’ “care”. I am haunted by the things I have seen and experienced. I cannot watch another person be neglected or bullied to death based on these myths. These myths are killing people. The information which contradicts and disproves them exists, so why aren’t clinicians listening?? Whatever the reason, I thought I would lay out some of the most prominent BPD healthcare myths here, with opposing views, contradicting information, and evidence which disproves them. I hope it provides a sort of reference library of counterarguments and information for people who wish to oppose these myths, including professionals in their clinical practice, activists, peer supporters, patients, carers, and survivors. This is a living document - if I have not covered a myth you think belongs here, let me know. The same goes for research I have overlooked, or new research not published at the time of writing this, let me know! (in the comments, or via twitter).
You can use the following to navigate:
Unfortunately the blog post got too big to include the hundreds of references, so they got their own blog post, here.
Myth 1 - “Hospital is dangerous for people with BPD, it makes them worse”
So, this is one of the most common healthcare myths about BPD - ‘hospitalisation is contraindicated, and is likely to, or will definitely, contribute to worse outcomes in this patient population’. When followed back through the literature, this idea seems to originate, in part, from the well-meaning attempt at reducing institutionalisation and increasing mental health community care [45,46]. Historically, particularly in countries like the USA, any mention of suicidal ideation could (and still can) get someone whisked away and locked in a psychiatric unit until the potential risk is reduced or eradicated [47,48]. The problem is, suicidality is not as simple as “suicidal - at immediate risk of death” and “not suicidal - not at risk”. Suicidal ideation, instead, seems to exist on a complex and ever shifting spectrum or continuum, where someone could feel tired of living and think about death, but not actually want to die; someone could take comfort in the concept of suicide being their “get out” plan for when things are bad; someone could exist for months or years with low level feelings of not wanting to carry on living, before the feelings suddenly shift and the person then starts making active plans to end their life..etc [49]. The difficulty for people who experience long-term “chronic” suicidal feelings (such as many people labelled with BPD): when suicidal ideation is enough to keep someone in hospital until it dissipates, chronic suicidality could lead to a lifetime of unnecessary hospitalisation. The concept of collaboratively supporting people who experience long-term suicidal feelings, in the community, therefore, seems rather sensible. In academic papers from the late 1900s, clinicians and researchers discuss patients with “chronic”, “long-term”, or “intractable” suicidality and this negative potential for extended hospitalisation [50]. Over time, these descriptive terms simply morph into BPD, with some authors even rediagnosing their historic patients with BPD based on memory or old case files [51]. Unfortunately, instead of just stating “unless acutely suicidal, people with long term, “low level” suicidality are generally safe to be supported in the community if they desire”, clinicians and researchers have instead pushed the unevidenced narrative that hospital care is actively harmful to people they have labelled with BPD, and that even when experiencing seriously high levels of risk, this patient group should only be hospitalised for extremely limited periods, if at all. Naturally this has been eagerly jumped on by clinicians who hold stigmatising views about people labelled with BPD, so as to avoid caring for them [52,53], and by healthcare systems such as the NHS, which want to do everything possible to avoid spending money [54,55].
Those who espouse this belief of “harm” cite a few sources, the most frequently mentioned being the 2002 paper “Chronic Suicidality Among Patients with Borderline Personality Disorder” by Joel Paris [56] and the 2004 paper “Is Hospitalization Useful for Suicidal Patients with Borderline Personality Disorder?” once again by Joel Paris [57]. Given that these papers are still being cited in research 20 years after publication, you would be forgiven for assuming they have a strong foundation of robust evidence supporting their claims. Unfortunately, you would be wrong. Throughout both papers, Paris makes numerous unreferenced sweeping statements regarding the unsuitability of the hospital environment for patients labelled with BPD, with only his opinion to support his claims. The handful of references provided are also based on the personal opinions of clinicians and one patient, and are identical in both papers. They are broken down below:
The most heavily leaned upon reference in both papers is an essay written in 1998 by a woman with a diagnosis of BPD, in which she describes her experiences of her own emotions and thought processes [58]. While this is an important and interesting read, unfortunately she extrapolates these deeply personal experiences to all people labelled with BPD, directing mental health professionals to never hospitalise people labelled with BPD for more than 48 hours, due to her personal experience of its unhelpfulness. It seems exploitative and disingenuous that Paris would use the experiences and opinions of one person like this, particularly given how many people labelled with BPD describe hospitalisation as life-saving for them, and having it withheld as traumatic and dangerous.
Another key reference is the 1993 book “Relationship management of the borderline patient” [59] which is filled with medical anecdotes from the authors’ clinical experience of mental health inpatient facilities in the mid to late 1900’s. The stories and clinical practices described within the book are disturbing, even when considering the era in which they occurred. Further to this, the author unashamedly writes that many of the patients in the clinical vignettes do not actually meet the diagnostic criteria for BPD, nor are his methods of treatment confirmed with controlled trials. The book states that people labelled with BPD should not be hospitalised, as this could encourage “ego regression”.
The 1994 paper, “Calculated Risks in the Treatment of Intractably Suicidal Patients” by John Maltsberger [60] is also heavily relied upon. It is a truly shameful publication. I would recommend great caution to those who intend on reading it. Maltsberger uses language such as “intimidating”, “coercive”, “blackmail”, and “sadistic” to describe patients sharing their suicidal feelings with clinicians. He states that patients labelled with BPD “remain indifferent to physical discomfort, hunger, cold, and pain, [seeking] out all kinds of suffering”, going on to say that BPD-labelled patients (described as “primitive”) can be differentiated from depressed patients who self-harm and/or feel suicidal, because patients labelled with BPD “are typically not particularly ashamed of self-mutilative or suicidal behavior”. Further to this is the unevidenced claim that “spiteful false accusations of sexual misconduct to colleagues or official agencies are increasingly common [from this patient group]” and that working with BPD-labelled patients may cause clinicians to experience aggressive and sexual fantasies. One such fantasy, of a male psychiatrist trainee, is described, where the psychiatrist became so enraged that an inpatient would not speak to him during appointments, mid-session he had a violent and vivid fantasy of murdering her. It was decided that the patient had generated this “sadistic fantasy and impulse” in the psychiatrist due to “extending into the environment around her” a component of her inner life she could not tolerate - despite not ever even speaking. Maltsberger concludes that “giving responsibility back to the patient for the decision whether to live or to commit suicide becomes not only ethically defensible but sometimes ethically necessary.”
Linehan is the next clinician used as a reference, with the 1993 book “Cognitive Behavioral Therapy of Borderline Personality Disorder” [61]. Once again, the decision to not hospitalise BPD-labelled patients is based on clinical opinion and behaviourist theory about “reinforcing” attention-seeking, rather than any form of robust or measurable evidence.
Finally, the use of the 1990 paper “Dilemmas in the Management of Suicidal Behavior in Individuals with Borderline Personality Disorder” [62] seems a strange paper to include. While it concurs with the majority opinion that people experiencing long-term suicidality should be supported in the community, it concludes that acute episodes of crisis in BPD-labelled patients should be treated just as any other patient in crisis, which includes hospitalisation.
For two papers so heavily cited and held up as proof that hospitalising this large, heterogeneous patient group is detrimental, they are both surprisingly void of evidence in support of their claims. The references supplied are outdated, prejudiced, contradictory, based on personal opinion, and frankly, contain some seriously disturbing and inappropriate material.
Despite the belief about BPD and hospitalisation being widespread throughout services, research actually finds that hospitalisation is not specifically harmful to people labelled with BPD, and does not contribute to worse outcomes or a deterioration in health [63-65]. In fact, as reported by Fowler, et al., in 2018, “current results indicate that extended inpatient treatment can result in significant and clinically meaningful symptomatic and functional improvement in BPD patients without iatrogenic effects.” [66] NICE guidelines for BPD even confirm this, stating there is “no evidence to support the assumption that admission to hospital is harmful for people with borderline personality disorder” [67]. NICE, and other professionals, caution mental health professionals to be aware that the assumption of harm originates from the opinions of individual clinicians, rather than any robust form of evidence [68-70].
While very little RCT evidence exists regarding hospitalisation in patients labelled with BPD, smaller, non-controlled studies often find hospitalisation to be helpful or at least no more harmful than outpatient care [71,72]. A small study conducted in Norway provided a group of patients with self-directed admissions over a period of 1-2 years, which were not reliant on the patient needing to be in crisis to access the admission. The majority of the patients had a diagnosis of personality disorder, and over the study period spent 5 days in hospital every 4-6 weeks. The study reported that “The incidence of all types of intentional self-harm was reduced after the introduction of the system of planned admissions. There was also less use of psychiatric health services, particularly emergency psychiatric services. For psychiatric patients with frequent episodes of intentional self-harm and high consumption of emergency psychiatric services, more use of planned admissions may be an alternative.” [73]
Myth 2 - “Suicide risk increases the longer people with BPD are in hospital”
Similar to the first myth is the specific idea that long inpatient stays are associated with higher rates of suicide in patients labelled with BPD. This is not found to be true, in fact, quite the opposite. Short term hospital stays of a week or less are significantly associated with higher suicide rates following discharge [74-77]. A recent study found that the risk of suicide both in hospital and after discharge were significantly reduced by longer admissions [78]. Further findings from a recent national clinical survey showed that people who ended their lives within a few days of inpatient discharge were frequently those with a personality disorder label, and were commonly subject to short hospital admissions [79].
Myth 3 - “NICE guidelines recommend 6–72-hour admissions for people with BPD”
NICE guidelines do not recommend this, anywhere, in either the long or short version of the BPD guidelines. This is one of the most ridiculous BPD myths, given that people saying this are quoting a document, which, if they care for people labelled with BPD, they should have read, but quite clearly have not. The 6–72-hour myth actually appears to originate from the 2003 book, ‘Borderline Personality Disorder: A Practical Guide to Treatment’, by Krawitz and Watson (below) [80].
In the original text, the concept of limiting BPD labelled patients to short admissions comes from the authors’ personal opinions, which are primarily supported by two references. The first is the same personal essay of a woman diagnosed with BPD, which was discussed earlier, in myth one [81]. The next is also an individual’s account of their experience of hospitalisation, as presented at a BPD conference in 1999 [82]. No other evidence is provided to support the argument that longer admissions are harmful, however, this book is used to provide clinical justification for the withholding of inpatient care in NHS mental health trust policy, including the Tees, Esk and Wear Valleys’ infamous “BPD+” protocol, a document publicly linked to patient deaths [83,84].
Myth 4 - “Self-harm in people with BPD can be best understood as a means of attention-seeking”
Some people self-harm as a means of communicating extreme distress or seeking compassion from others, and this is just as deserving of a caring and non-judgemental response as any other reason. However, a large body of research has found that this is actually one of the least common reasons for self-harm, including in people labelled with BPD [85-88]. The most common reason is consistently found to be a means of coping with difficult, distressing, or overwhelming emotions, while other reasons include inducing or ending a dissociative state; reducing suicidal feelings; asserting control over oneself; self-punishment; coping with sensory overload; and sensation seeking [89-95].
Along with this myth being factually incorrect, it is also important to note the subtext of the myth - the demonisation of “attention-seeking” [96]. Seeking attention is not an inherently bad thing. We seek attention as a normal part of life. Calling or texting a friend is seeking attention; making a GP appointment is seeking attention; posting pictures of your food or pets on social media is seeking attention; asking for help in any context is seeking attention. If someone is harming themselves as a means of seeking attention to communicate their distress, it is incredibly important that they are listened to, and questions be asked about why they were not being heard before. While people may feel a range of negative emotions upon witnessing self-harm, such as anger, disgust, fear, confusion, and annoyance, the subsequent belief that the individual who self-harmed did so to deliberately provoke these feelings, is not supported in research [97]. The stigmatisation of self-harm and its conceptualisation as a deviant manipulative behaviour by healthcare services is commonly internalised by people who self-harm, and can lead to people not seeking help, keeping their self-harm secret, and increasing the severity of the harm, so as to appear “valid” and “genuine” [98,99].
Myth 5 - “Providing a caring response to people with BPD following self-harm reinforces this behaviour and makes them do it again”
This is a distressingly prevalent myth, which causes an immense amount of harm to people who are already incredibly vulnerable. It originates from the field of psychology known as “behaviourism”. I will give a very short, simplified overview of behaviourism in this context. Behaviourism considers behaviour to be produced largely by a person's interaction with their environment, driven by four basic functions: escaping/avoiding something, attention-seeking, seeking a tangible reward, and self-stimulation [100]. The response to a particular behaviour can teach the person to repeat or not repeat the behaviour [101]. For example, if a child screams in a shop for a new toy and they are rewarded with a toy, the screaming behaviour is reinforced, and likely to reoccur. If the screaming is ignored or punished, and they are not given a toy, the behaviour is likely to cease, as it was punished/not reinforced. The “function” of the behaviour is the important part to note here. The child is screaming for a toy, and as such, withholding the toy teaches them that screaming will not be rewarded with a toy. If the child was actually screaming because they were overwhelmed by the lights/sounds in the toy shop, not buying them a toy would not stop them screaming, because seeking a reward was not the function of the screaming.
While I disagree with the use of behaviourism in understanding and treating self-harm, theoretically, it can be considered in this manner. If a person self-harms because they want someone to show them kindness or compassion, and they are subsequently treated with kindness/compassion in response to self-harm, theoretically, this could “reinforce” the behaviour, and encourage them to self-harm again the next time they wish to seek kindness/compassion. (In clinical practice, deliberately withholding compassion so as to not reinforce the behaviour is sometimes referred to as “withdrawal of warmth” [102,103]). As I said, the function is the important part to consider here, and as discussed in the previous myth (no.4), the most common function of self-harm is not interpersonal influence, but a means of coping with difficult and distressing emotions [104-110]. If a person self-harms to relieve negative emotions, and the self-harm succeeds in doing so, the reduction of the negative emotion is what reinforces the self-harm. This is known as automatic reinforcement: the action reinforces itself with no external/social input needed [111]. If we view the situation as a closed loop, it would look something like this: “difficult emotion” ----> “self-harm” -----> “reduction/end of difficult emotion” -----> “self-harm reinforced and may occur again”. The interesting and sad thing about the person then receiving an uncaring/discriminatory response upon seeking medical attention, is that it forms another closed loop: “person seeks medical attention for injury” -----> “unpleasant response” -----> “person learns not to seek medical attention”. An unpleasant response from healthcare workers does not work to undo the reinforcement of self-harm, rather, it teaches the individual not to seek help following self-harm. Uncompassionate or otherwise unpleasant responses to self-harm are also consistently found to lead to an increase in self-harm and negative feelings, such as shame, guilt, and self-stigmatisation [112-114].
Returning to self-harm as a means of communication: the theoretical basis of support for a behaviourist approach to self-harm which serves an interpersonal function, does not mean withholding care is a legitimate or effective intervention in actual clinical practice. It is not. There are several reasons why:
It is cruel. It ignores the underlying need the person has for human connection, and gives the message that they are being “bad”. There is a reason the person needs attention, and that need must be met. Crushing the expression of this need does not end the need. It may even increase severity/frequency of self-harm by causing shame/self-loathing/despair [115]. When someone is crying out in pain, the compassionate response is not to shut the door in their face.
It is dangerous. Whatever the function of the person’s self-harm, the potential immediate risk of serious harm or death should not be ignored in favour of some nebulous, staff-directed, long-term goal. Self-harm practices carry numerous potentially fatal risks, including blood loss, infection, internal organ damage, asphyxiation, etc. which are not modified by the function of the self-harm. Self-harm is also the most important risk factor for suicide [116]; one in seven adults who die by suicide have been treated for self-harm in the preceding year [117]. This indicates that when people seek help following self-harm, services are presented with an opportunity to intervene and offer support. Withholding care or ignoring someone following self-harm would preclude this.
Withholding attention to reduce self-harm presents a significant danger to the individual who is seeking attention. This relates to a phenomenon known as an “extinction burst”, which involves an initial, sometimes extreme, escalation or surge in the target behaviour, as the person makes increased attempts to have their needs met [118]. If, for example, the person is repeatedly cutting their arms as a means of seeking human connection/compassion, and healthcare services decide to stop responding, the person could increase the frequency and/or the severity of the cuts in order to try and have their need for connection/compassion me. This could potentially lead to serious harm or even death.
It fundamentally misunderstands the fluid and ever changing nature of self-harm. Self-harm is not static. It may serve numerous functions in just one individual, sometimes all at once, or sometimes at different times [119,120]. Someone could self-harm in the morning for interpersonal reasons, and then self-harm in the evening for emotional regulation. Blanket assessments which conclude that self-harm only serves one function do not take the ever changing and developing nature of self-harm into account, and ignore NICE guidelines which recommend every incident of self-harm be assessed separately: “When caring for people who repeatedly self-harm, healthcare professionals should be aware that the individual's reasons for self-harming may be different on each occasion and therefore each episode needs to be treated in its own right.” [121]
Updated NICE self-harm guidelines (September 2022): “each episode of self-harm should be treated in its own right, and a person's reasons for self-harm may vary from episode to episode” pg16 [122]
Interestingly, historical literature (which is often more likely to contain blunt and (horrifyingly) truthful personal accounts from clinicians) indicates that while behaviourist theory may underlie the clinical intervention, withholding care and compassion provides staff with emotional relief or an outlet for their feelings of anger, guilt, and hostility towards the patient - perhaps suggesting something about the true motivation of such interventions. The following extract from a paper about responding to self-harm, describes how staff being allowed to express their feelings of anger and frustration towards someone who self-harmed made them feel better: “I became more spontaneously and directly expressive of the actual feelings aroused by her - particularly angry ones - and other staff members were encouraged to be more honest and clear in the expression of their feelings. They were instructed that it would be growthful - that is, not destructive - for Jane to learn of the more genuine interpersonal consequences of her behavior. This relieved much of their tension and pent-up feelings, including guilt, and provided a constructive, sanctioned outlet for their anger. [...] I verbalized to Jane that when she cut herself she was cutting me, tearing me apart. This was not presented to her as a symbolic interpretation but as a feeling experience of mine in relation to her. I insisted that she handle her feelings in some other way. [...] On another level, since I had a strong wish to help her, I truly did experience great pain when she cut herself, and I wanted to share this with her. At still another level, in terms of my selfish desire to be a potent therapist, I felt hurt and impotent and angry. This, too, I wanted her to know.” [123]
Overall, whatever the function self-harm serves for the individual who is self-harming, they deserve a compassionate, trauma-informed response from services. Punishment, dismissal, and other forms of discriminatory responses can be traumatising and elicit shame, self-loathing, self-stigmatisation, an increase in self-harm, and a decrease in help seeking [124,125]. The new NICE guidelines for self-harm (September 2022) also now explicitly state: “punitive or aversive approaches should not be used, [...] such approaches are considered malpractice and often have harmful effects on people who have self-harmed, potentially leading to increased distress and repeat self-harm or suicide.” (pg 59) [126]
Myth 6 - “Women and girls who self-harm have BPD”
While this myth is not said out loud as often as many of the others, it can be inferred from the actions of clinicians who frequently apply BPD labels to women/girls (and AFAB trans/non-binary people wrongly perceived as women/girls) based solely on a history of self-harm [127-129]. The stereotypical “self-harmer” in western societies is a young, white female, however, self-harm is actually prevalent across all genders, ages, ethnicities, and both clinical and non-clinical populations [130]. While self-harm is frequently associated with mental illness, it is also common in neurodevelopmental conditions; pain disorders; rheumatic conditions; neurological conditions; learning disabilities; in trauma survivors; and in children with neonatal birth injuries [131-136]. Self-harm is observed in numerous non-human animals, including primates, rats, birds, and horses [137-140]. It is also present in many religious, spiritual, and traditional cultural practices worldwide [141]. Attempting to compress self-harm into a small box marked “BPD” fails to appreciate its biopsychosocial complexities, and erases the lived experience of the vast and diverse population of people who self-harm. Further to that, for individuals labelled with BPD due to self-harm, the BPD label can work to end all clinical curiosity regarding their needs and reasons for their actions: “we know the individual has BPD because they self-harm, and they self-harm because they have BPD, which is how we know they have BPD…”etc [142-144]. They are left to languish in this infinite circular argument forever - their individuality permanently erased.
Myth 7 - “People with BPD are at high risk of accidentally kill themselves while doing something dangerous for attention”
This is an extremely common belief espoused by researchers, services, and even mental health charities. Interestingly, despite its unquestioned acceptance as “truth”, it has been very difficult to find any information which confirms it. In general, risk of accidental death is higher in people with mental health conditions than people without [145]. Accidental death in this context includes vehicular accidents, falls, and substance-related deaths. While some studies find the risk of accidental death higher than the risk of suicide in this population, others find the opposite [146]. High risk groups for accidental death mirror those for suicide: middle aged men, low socioeconomic status, unmarried, unemployed. While several studies have found higher rates of accidental death in people labelled with “personality disorder” as a whole group[147,148], I have not been able to find any studies which have compared the rates of suicide and accidental death in people specifically labelled with BPD. A 24-year follow up study which looked at the outcomes of 290 people who met BPD diagnostic criteria (and a non-BPD control group of 72 people) reported a high incidence of non-suicidal deaths, which included deaths from cardiovascular disease; substance-related illness such as liver cirrhosis; cancer; and finally, accidents [149]. Unfortunately, while the study reported 5 deaths due to accidents, this figure was from both the BPD and control group, and as such, it is not possible to know how many, if any, of the BPD group were included. Even if all accidental deaths were from the BPD group, this only accounts for 1.7%, in comparison to 5.9% who died by suicide.
[Content warning: Suicide methods]
The idea that self-harm could “go wrong” and the person accidentally die, seems logical, but despite it being said frequently, there appears to be a dearth of research which supports this occurring on a frequent basis. If there are higher rates of accidental death in BPD populations (which I can’t find evidence to support) there are some reasons which could account for this. The verdict (suicide/ accident/ misadventure/ narrative/ etc) given by coroners is significantly related to the method of death. People who end their lives by hanging or gunshot are much more likely to be given a verdict of suicide, than people who end their lives by self-poisoning, jumping, or drowning [150]. Self-poisoning is the most common suicide method in people labelled with BPD [151], which could be related to the high numbers of women in this population, as this method is more favoured by women than men. As such, it seems conceivable that a certain percentage of deaths in people labelled with BPD are incorrectly classified as accidental, due to coronial opinion of the relationship between method and intent [152-154]. Further to this, in the discussion of accidental death in people labelled with BPD, it's very important to keep in mind the tendency of mental health practitioners to disbelieve, belittle, rewrite, and override the behavioural intentions of people they have labelled with BPD, including at inquest [155]. Many people in this patient group who have suicidal intent are not believed, and their suicide attempts are rewritten as self-harm or attention-seeking, while their attempts at asking for help are labelled “suicide threats” and shut down as a form of manipulation. As one author writes, “It is hard to reconcile how they could both be the most suicidal patient group, and yet simultaneously perceived as presenting their suicidality as a means to attention.” [156] This is how it is reconciled. By reframing “suicide” as an accidental outcome of someone merely performing a risky activity for attention, people labelled with BPD can have high suicide rates while simultaneously not be considered genuinely suicidal.
This is where it becomes important to not only look for evidence for/against this myth, but to consider the purpose it plays. The first comes in the form of defensive practice. Informally, accidental death is considered less serious, less tragic, and less legally damaging to mental health trusts and individual clinicians, than suicide. The shift from suicide to “accidental death while attention-seeking” adds a layer of deliberate intent, implying blame, as it didn’t come from a place of suicidal distress/hopelessness, but rather one of manipulation or even malice. The thought process seems to be that if someone ends their life because they were depressed/psychotic/hopeless/defeated/etc they were failed by services, as they were owed care. However, if someone else ends their life by accident after choosing to do something dangerous because they wanted to elicit a response from someone, this was their fault, and services could not have predicted or prevented this. Despite this seeming to make sense on an emotional level, it makes no logical or (more importantly) legal sense that if your patient ends their life by accident, you should face less scrutiny than if they ended their life in the exact same way, but with suicidal intent. See myth 8 (misadventure) for further discussion of this. The next purpose to consider is the use of punitive behavioural techniques. If someone is doing risky things to try and get people’s attention, or “pretending” to be suicidal/attempt suicide to manipulate and/or control others, clinicians can present punitive and coercive interventions as a “legitimate” response. In this sense, the genuine distress, hopelessness, and intent to die are wiped away, and the person is not met with sympathy, compassion, or care, rather, they are demonised, and even criminalised because they can be blamed for their “bad behaviour” [157].
Myth 8 - “People with BPD are at high risk of dying by misadventure”
Following on from above, risk of suicide in people labelled with BPD, is frequently reassessed and recorded as risk of death by “misadventure” in patient notes. Although colloquially, the terms misadventure and accident are sometimes used interchangeably, at inquest, “accidental” and “misadventure” verdicts have different legal meanings. Accidental death indicates that the action undertaken which caused the death was not intentional - either by the individual who died/or by another, such as a healthcare practitioner. Misadventure indicates that while the intention of the action was not to cause death, the action was undertaken deliberately. An example could be someone dying “accidentally” because they tripped and fell from a cliff while walking, while someone else died by “misadventure” as they deliberately jumped from the cliff, but they did not intend to die. While a limited number of studies have looked at causes of death in people labelled with BPD, I am yet to find anything which discusses misadventure.
The word “misadventure” in clinical practice seems to serve one purpose; the reframing of a potential or apparently imminent patient suicide as being the patient’s fault, rather than the responsibility of the clinician [158,159]. I have several thoughts on this. Firstly, healthcare professionals need to dispense with the use of the word “misadventure” in clinical practice. It is the responsibility of the coroner to assess and reach a verdict on the classification of violent and unnatural deaths, not the responsibility of mental health staff. Coroners conduct in-depth investigations into deaths, which include an inquest in court, sometimes preceded by years of information gathering, before they, or a jury, reach a decision on intent. Misadventure is a legal term, not a clinical word. Clinicians have no business pre-designating the legal intent behind a self-inflicted death which has not yet even occurred. From a patient perspective, discovering this in your medical notes is incredibly disturbing. I found this a few years ago in a risk assessment done by an OT who met me once. We didn’t even talk about suicide. It made me feel both entirely misunderstood, and as if I was considered a hopeless, lost cause to services. I felt worthless, dismissed, disbelieved. They were already predicting not only my death, but invalidating me by saying if I did die, it would be while I was attempting to do something else.
For some reason mental health clinicians seem to think “misadventure”, as opposed to suicide, reduces their responsibility and ameliorates any potential for blame. Legally, a clinician recording that their patient is at risk of accidental death rather than suicide, does not discount the clinician’s duty towards them, nor does it remove the patient’s legal protections, or their right to life under the Human Rights Act 1998. Clinical staff are bound by a legal duty to protect their patients from reasonably foreseeable, avoidable harms, which includes harms caused by the actions or inactions of the clinical staff [160]. Attempting to erase or reject this legal duty by replacing the patient’s status as suicidal (therefore “ill” and in need of treatment) with attention-seeking (therefore “badly behaved” and not in need of medical care) is invalid [161]. Medical staff cannot both claim mastery over individuals and their behaviour, based on their medical diagnosis, while also uncoupling themselves from the responsibility they subsequently have to care for and protect that person. The clinical authority by which the clinician makes this judgement is based on the diagnosis of BPD, which, as an officially recognised medical diagnosis, provides the patient with the protections afforded by this status, including a duty of care from appropriate service providers. Further to the statutory duty of care comes the protections afforded by the Human Rights Act: Article 2 Right to Life. As mental health trusts carry out state functions, they must uphold the human rights of their patients, which not only includes the duty to provide a robust regulatory framework (such as adequate policies and protocols), but also the duty to proactively protect certain individuals where there is a real, immediate and foreseeable risk of death [162]. Asserting that a vulnerable person is at risk of death by misadventure rather than suicide, does not disengage the clinician’s or the service’s legal duties of care and protection - no matter how much the individual clinician declaring “misadventure” wishes it so.
Myth 9 - “Providing care to people with BPD makes them dependent and that leads to poor clinical outcomes”
So this is another frustratingly common myth about BPD which suggests that people labelled with BPD are particularly susceptible to becoming “dependent” on any and/or all care they receive (including hospitalisation, crisis care, community care, etc.) which then subsequently results in them not “recovering”. The consequence of this myth for many people is the removal or withholding of care they desperately need, including blanket bans on hospital admission, and reduced community and crisis support.
There are several components to break down here, including what “dependency” means in this context, and how dependency impacts clinical outcomes.
The reason mental health services feel able to discharge or withhold care from people on the basis of avoiding dependency, is because they have decided that dependency is a bad outcome, something to avoid, a risk. This conceptualisation of dependency on others as inherently negative is based on western social ideals which celebrate independence over interdependence[163,164]; neoliberal policies in health services which prioritise reduction of healthcare provision to save money [165,166]; discredited Freudian theories of disturbed psychosexual development [167,168]; the unproven belief that dependency causes psychosis [169]; ableism and misogyny in historical research which conceptualised dependency on others as sign of weakness and femininity [170-173]; and personality disorder stigma within clinical environments [174,175].
Considering dependency on others a character flaw is inherently ableist in its lack of consideration for people with long-term care needs due to chronic illness and disability. It also stigmatises and pathologises people who come from communities and cultures with greater levels of interdependence.
Within services there is a misperception that dependency on others is a single construct based on personality type. In actuality, in the mental health environment, dependency can be considered two distinct constructs:
“Trait dependency”: Increased dependency on others, related to personality type, culture, upbringing, socialisation, trauma etc.
“Care dependency”: Increased dependency on health services and staff, related to independent factors associated with the provision of healthcare services.
Research finds that trait dependency and care dependency are not correlated [176,177]. This is important to note, as the rationale behind withholding care from people labelled with BPD is that they are more at risk of becoming dependent on care, because they have “dependent personality traits” [178,179]. However, people with increased trait dependency are not at a statistically higher risk of becoming dependent on healthcare services [180]. This indicates that even if people labelled with BPD or BPD traits are all somehow more likely to be “dependent”, they are not more likely to become dependent on care than other patients. In reality, mental health services can produce care dependency in any patient through numerous means, including expecting compliance; responding punitively or negatively to patients who question the care model/treatment choice/care plan; enforcing inflexible rules; establishing controlling environments; expecting high levels of gratitude from patients; removing freedom of choice; isolating patients; a lack of clarity about service aims and rules; and leaving patients out of care planning and decision making [181]. A reduction in self-efficacy is suggested to be one dependency-related side effect of hospitalisation in BPD-labelled patients. However, as noted by the Langley-Price report, research into hospitalisation and self-stigma indicates that self-efficacy could be reduced in people who spend time in hospital, due to internalisation of stigma, prejudice and discrimination they are exposed to from high levels of contact with mental health professionals [182].
In general, “care dependency” is under-researched and the little research which does exist is contradictory. One common finding indicates that higher than usual dependency on care or care providers has the potential for both negative and positive impacts on patient care and clinical outcomes [183,184]. Research looking into the positive aspects of dependency finds that care dependency does not negatively impact on treatment outcomes; may be crucial to positive clinical outcomes; and is often a temporary phase before the patient becomes fully autonomous [185,186]. Little to no empirical evidence exists to confirm staff perceptions that care dependency leads to treatment which is longer than clinically necessary [187]. In actuality patients with higher levels of care dependency are found to perceive their therapeutic alliances more positively, leading to higher rates of engagement and better treatment outcomes; have increased feelings of safety and comfort within services; miss fewer health appointments; are more engaged and “compliant” with treatments; and are actively involved in seeking care rather than passive recipients of services [188-193].
Discharge from services or a reduction in care, sympathy, compassion, and understanding from staff in response to the perception of patient dependency is well-documented and can be seen as a form of malignant alienation, increasing the risk of patient suicide. For further discussion of the impacts of withholding care, see Myth 10. Withholding otherwise appropriate, clinically-indicated, potentially life-saving care from patients labelled with BPD, to avoid the “risk” of dependency is entirely unjustified and dangerous. Care dependency is not inherently harmful, and in fact can be helpful and even necessary for successful interventions. Further to that, “BPD” does not produce dependency, rather a collection of factors including the clinical environment and the behaviour of staff contribute to dependence on services. Finally, having interventions such as hospitalisation and crisis care withheld to avoid dependency indicates that mental health services are prioritising the avoidance of dependency over helping keep their patients alive. Being dead is not better than being dependent.
Myth 10 - “Withholding care from people with BPD makes them take responsibility for themselves”
Withholding or withdrawing care in an attempt to force patients to “take responsibility” appears to be based on a collection of factors. These include the belief in staff that the “behaviour” being displayed by the patient (self-harm, suicidality, emotional distress etc.) can be controlled by the patient; the belief that the “behaviour” is manipulative, attention-seeking, made up, etc; the belief that the patient does not deserve support from healthcare services; the belief that the person is displaying a “behavioural” problem, not an illness or the psychological consequences of trauma; staff desire to avoid interacting with and caring for people they have labelled with BPD; a punitive response from staff who want to punish patients; and an attempt in staff to excuse resource rationing by creating a vaguely “clinical-sounding” reason to withhold care.
As described by Kealy and Ogrodniczuk, “stigmatizing attitudes among care providers and planners may fuel the lack of services designated for this population. In turn, the lack of resources—combined with the sometimes desperate seeming efforts of individuals to obtain help—can further cultivate an identity of BPD sufferers as “others” who individually perpetuate their own problems. [...] This can result in an overall neglect of services for patients with BPD, overriding the sensitivities of individual clinicians and fostering a climate of exclusion and marginalization regarding this disorder.” [194] Withholding care on the basis of the diagnosis of BPD is discriminatory, breaches the Equality Act 2010 [195] and does not follow NICE guidelines. The first of the general principles in the NICE guidelines for BPD states “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.” [196]
As previously discussed (myth 8), clinicians cannot escape their duty of care by merely refusing to treat specific patients. Clinical staff are bound by a legal duty to protect their patients from reasonably foreseeable, avoidable harms, which includes harms caused by the actions or inactions of the clinical staff [197]. Attempting to erase or reject this legal duty by replacing the patient’s status as suicidal (therefore “ill” and in need of treatment) with attention-seeking/manipulative/behavioural/dramatic (therefore “badly behaved” and not in need of medical care) is invalid [198]. As mental health trusts carry out state functions, they must uphold the human rights of their patients, which not only includes the duty to provide a robust regulatory framework (such as adequate policies and protocols), but also the duty to proactively protect certain individuals where there is a real, immediate and foreseeable risk of death [199]. Research exploring mental health professionals’ emotional responses to patient risk finds that staff may be desensitised to the possibility of a patient harming themselves or dying [200,201]. In one study, staff indicated that they resented being made to feel responsible for behaviours which they felt patients could control [202]. As one professional stated: “she might say ‘oh if you try and evict me I’ll overdose’ or whatever, well there’s nothing we can do to stop that and we have to remind her for example that it’s her responsibility, she can’t put the blame for an overdose attempt on other people.” [203]
Earlier this year I published the findings of my study into the phenomenon of patients being told they have the capacity to kill themselves. The word “responsible” was used frequently by respondents to the initial questionnaire, with over 70% of respondents stating that staff had told them suicide was their choice, and they were responsible for not killing themselves. Some people even described this being said to them while they were detained under the Mental Health Act. Descriptions of these experiences indicate that mental health professionals appear to believe that reliance on services during suicidal crises reduces a persons responsibility for their own safety, and as such, withholding care during these times encourages people to keep themselves safe. When questioned about this, 96% of respondents disagreed that having care withheld helped them retain responsibility for their safety, and 100% reported that having care withheld had placed them at risk [204].
“Absolute silence leads to sadness. It is the image of death.” - Jean Jacques Rousseau
Such a deliberate withholding of care could be described as ostracism of the patient; an action perceived as ignoring and rejecting a person or group of people [205]. Ostracism is consistently found to be profoundly harmful [206,207], even when only experienced for a short period or by remote means [208,209], as it threatens the human need for control, self-esteem, belonging, and meaningful existence [210]. Research finds that being ostracised powerfully interrupts a person’s ability to self-manage their emotions and behaviour [211], eliciting a wide range of negative emotional reactions, including anger, sadness, despair, loneliness, anguish, helplessness, worthlessness, shame, anxiety, and depression [212-215]. People experiencing ostracism may internalise their feelings and reasons for being ignored; punish themselves; self-harm; use substances; and even attempt suicide in response [216-218]. People who already have mental health conditions, such as anxiety, are at a higher risk of experiencing the negative effects from ostracism [219]. As described by a mental health service survivor: “I’ve asked for help so many times this year when I’ve felt suicidal and at risk and nothing has happened. Every time I ask for help and get none but I don’t die it seems to reinforce to them that I never need help because I can keep myself safe. That doesn’t really matter though. What no-one ever considers is that the act of being ignored when reaching out for help and feeling desperate is so soul crushing that every time this happens I feel as if I am a little bit less human.” [220]
Within mental health services, the concept of “malignant alienation” was created by Howard Gethin Morgan to describe a process in which patients experience a progressive and destructive deterioration in their relationships with mental health staff. This was suggested to occur when staff conceptualise the patient’s behaviour as “deliberately manipulative”, “provocative”, “unreasonable”, or “overly dependent” [221]. The process of malignant alienation includes a loss of care and sympathy from staff, and is associated with high rates of patient suicide [222,223]. Studies which have looked into suicide motivational factors have found similar results, reporting that mental health patient suicides can be precipitated by the withdrawal of care; the insistence patients be “independent” before they are ready; the avoidance of patient dependence placed above patient wellbeing; and the withholding of safety measures to “foster responsibility.” [224-226]
In the early 1970s an independent inquiry was launched to investigate the care approach at Napsbury Hospital in Hertfordshire, after the death of a patient. The inquiry found that Dr Scott, the psychiatrist managing one of the wards, had implemented a care plan for all patients in which they would “take responsibility for themselves” [227]. Ultimately this ended in patients being neglected. The patient who died on the ward had been injured two weeks before her death, but staff had not noticed. Numerous complaints were made by concerned family members regarding risk, patient neglect, unhygienic and unsafe conditions on the ward, and the withdrawal and withholding of care [228]. Dr Scott defended his care methodologies by stating that this was all a “necessary part of the treatment regime” and that those complaining just didn’t understand [229,230]. This was not enough to satisfy the investigation, however, and the ward was closed.
Ultimately, there is no evidence that withholding care to encourage “responsibility” in patients labelled with BPD is effective in reducing patient risk or increasing quality of life. The evidence which does exist indicates the opposite; doing so increases levels of emotional distress, worthlessness, and risk of suicide and self-harm.
Myth 11 - “Crisis care for people with BPD should be short and sweet” “Less is more” “Less intensive intervention is optimal”
Currently, there is no adequate randomised controlled trial (RCT) evidence supporting any specific crisis intervention for BPD-labelled patients [231-234]. The most recent review of evidence for crisis intervention in BPD-labelled patients (published September 2022) found very little evidence for or against any particular intervention, but noted that an RCT conducted in Sweden found that a programme in which people meeting the criteria for BPD could self-refer to hospital for brief admission during crisis, did not have more negative outcomes in comparison to treatment as usual [235]. The literature review concluded: “There remains a lack of high‐certainty evidence from RCTs on the efficacy of crisis interventions for people diagnosed with BPD. This review included two studies of two very different types of crisis intervention (joint crisis plans and brief admission to psychiatric hospital by self‐referral), and found no clear evidence of a benefit over treatment as usual in any of our main outcomes. Crisis points are distressing for patients and their families, and are difficult to manage for clinicians, due to the lack of evidence on the effectiveness of crisis‐specific interventions. The evidence base has changed little in the 10 years since the original version of this review was published, and there is a pressing need for research into appropriate interventions that can guide practice.”
The 2018 report Safer Care for Patients with Personality Disorder found that patients labelled with a personality disorder who died by suicide were not receiving care consistent with NICE guidance [236]. Concerns were raised by both staff and patients regarding sporadic contact from services, a failure to address past trauma, and inappropriately short lengths of post-crisis support. These service failures were felt to contribute to vulnerable patients moving from “crisis to crisis” [237].
A recent large scale RCT looking at low intensity community treatments for people who self-harm and experience frequent suicidal ideation found that brief dialectical behaviour therapy skills training (presented in a brief online format with no in-person visits or group therapy) significantly increased the risk of fatal and non fatal self-harm, when compared with usual care [238]. Risk of self-harm among those offered DBT skills training was approximately 30% higher than in usual care. While the study was unable to provide reasons for the increased risk, it reported that the limited nature of the interventions themselves may have been dissatisfying and caused people to become even more discouraged. The study did not support implementing this approach.
The suggestion that people labelled with BPD are best served with reduced levels of crisis care is not based on any form of evidence. Once again, the most likely motivation behind this apparent clinical decision is a desire to avoid working with this patient group.
Myth 12 - “Positive risk taking is the most effective form of intervention for people with BPD”
Positive risk-taking, also known as ‘therapeutic risk-taking’, is a risk management concept used in numerous health and social care service interventions and practices. It is based on the understanding that “risk” is an immutable part of life, and cannot be entirely eradicated, nor should it be, as taking certain risks can lead to positive outcomes and personal growth which may otherwise have been inaccessible. Within mental health care, moving away from overly risk averse practices is a deliberate act which recognises that when mental health practitioners are too risk averse, they can restrict patient freedom; choice; potential for growth; and, for some, recovery [239]. “Positive risks” in this sense are actions or inactions, taken in the service of recovery/growth/empowerment/autonomy/etc with the knowledge that they hold some risk.
Although positive risk-taking is now recommended practice by the Department of Health, and an expected clinical capability in numerous mental health professions [240], there are conflicting accounts of its safety, efficacy, professional understanding of the concept, and how it affects patients. Literature on the topic indicates that positive risk-taking is under-researched, not well understood in practice, lacks any kind of formal evaluation in terms of patient outcomes, and little is known of its “dimensions and value” in patient care [241-243]. I have also been unable to find any research which supports/evaluates positive risk-taking in patients labelled with BPD, or considers how it may be misused, and how to safeguard against the possibility that it could be used in services as an excuse to neglect.
Anecdotally, positive risk-taking appears to be an intervention extremely vulnerable to misuse, and is often included in people’s risk management plans without their knowledge or consent. Patient/survivor accounts detail times people in vulnerable positions have been forced to take risks (discharged against their will, left to cope alone during crisis, had care removed, etc) due to the belief of clinicians that such actions will allow patients to become more responsible, learn to manage their own risk, and eventually reduce their service use [244-246]. Positive-risk taking, by its very nature, often involves a reduction in care provision and/or reduced interaction between staff and patients, opening it up to potential misuse in situations where staff want to avoid working with a particular patient or group of patients [247]. Given that people labelled with BPD (or perceived by staff to fulfil the BPD clinical stereotype) are heavily stigmatised within services; avoided; dismissed; considered to be attention-seeking rather than unwell, more responsible for their behaviour, and “undeserving of NHS resources” [248-253], it follows that an intervention like positive risk-taking, in which people have care reduced to encourage self-responsibility, would be at high risk of being misused with this patient group. Positive risk-taking provides the perfect answer for staff looking to avoid or punish patients they dislike or find difficult to interact with, because staff can actually insist that withholding care is therapeutic and in their patient’s best interests, despite there being no evidence to support this.
As described by survivors:
“In the last few years I have been left in high risk situations, because of the misuse of enforced positive risk taking. [...] It seems to be shorthand for “We don’t give a fuck.” Surely, services should not withhold support and care when I’m at serious risk of harm under the guise of it being in my best interests, to teach my badly behaved personality a lesson, as a way of tapering care to somehow facilitate resilience, or in a way to avoid blame. You’re actually gambling with my life. It’s scary! Positive risk taking – positive for who? It’s no good promoting recovery if I’m dead!” [254]
“[T]he trauma I have been caused as a result of [services] withholding care is immense. I will not subject myself to this abuse any longer and now do not engage with them at all. There is no help for people like me." [255]
“I was told repeatedly that if I wanted to kill myself it was my decision to make. [The psychiatrist] stated very matter-of-factly that his only priority was to ensure that his back was covered legally, and that if I were to kill myself, he felt he could justify his decision to allow me to do so in a coroner’s inquest. I was told that ‘some psychiatrists would play it safe and section you to keep you alive’, but he felt that wasn’t best for me because he wanted me to ‘take some responsibility’. [...] Discharging someone with expressed suicidal intent is the equivalent of discharging someone in the middle of a heart attack, there is nothing positive about positive risk taking, you’re gambling with people’s lives.” [256]
Given that positive risk-taking is a planned action or inaction in service of patient recovery/empowerment/increased wellbeing, it would be reasonable to consider it a clinical “intervention” (as it is a deliberate decision designed to result in an outcome) [257]. Unless in very specific circumstances (such as certain treatment under the Mental Capacity Act or Mental Health Act), clinicians must seek and be provided with consent to carry out interventions on/with patients [258-261]. Positive risk-taking is not excluded from this legal and ethical requirement. Further to that, positive risk-taking in situations relating to self-harm and suicide has the potential for seriously harmful outcomes, including death. The “risk” in this situation is borne by the patient, not the staff. If staff choose to disbelieve a patient about their risk levels and dismiss the patient’s requests for help, instead employing a negligent positive risk-taking approach, it is not their lives which risk being lost to suicide. As such it is entirely reasonable to expect that positive risk-taking only be undertaken with the full knowledge and informed consent of the person taking the risk - the patient. As noted by the Department of Health: “Providers and/or commissioners could [..] be exposed to litigation if they place people in a position of risk. There is an important distinction between putting people at risk and enabling them to choose to take reasonable risks.”[262]
Overly risk averse practice is criticised for being coercive, restrictive, disempowering and removing patient choice. Positive risk-taking which is forced upon someone (termed “coercive risk-taking” by some patients/survivors) is just as coercive, restrictive, disempowering, and removes just as much patient choice as overly risk averse practice. Swapping out one practice for the other does nothing to increase autonomy if patients are still not included in decisions about their own lives. Staff frequently insist that having care withheld enables patients to take responsibility for themselves, which is supposedly empowering. Survivors disagree. There is nothing empowering about being compelled to take risks you are not comfortable with or feel able to safely manage. Being forced to cope alone during a crisis can be experienced as deeply traumatising; can have long term effects on a person’s engagement and trust in services; and can increase thoughts and feelings of hopelessness, worthlessness, and suicidal ideation [263].
Myth 13 - “Patients with BPD have the capacity to choose to end their lives if they want to”
One of the more disturbing practices coming to light within mental health services is the misuse of the Mental Capacity Act to withhold care from suicidal people who are requesting - sometimes begging - for help. Many people presenting to mental health services, ringing crisis teams, going to A&E, being detained by the police under section 136 of the Mental Health Act are being told they “have the capacity to choose to kill themselves” and as such, services somehow cannot provide support. They are then turned away, discharged, hung up on, or told to leave. Further to this, in some cases mental health services are also directing other professionals, including A&E staff, paramedics, and the police to withhold care from people they have decided “have capacity”. It appears this phenomenon is most frequently targeted at young women, often with a label of personality disorder or perceived by services to fit the clinical stereotype of personality disorder.
Without any research directly asking clinicians why they are saying this, it is difficult to say for certain the exact clinical motivation which underlies it in individual staff, however, some reasons have been speculated, including: an excuse to withhold care due to lack of resources; an excuse to withhold care from people who staff do not feel are deserving or who they dislike; the calling of the patient’s “bluff” because staff do not believe they are truly suicidal; an attempt at defensive practice; ignorance about suicide, mental health/capacity law, and professional duties of care; and the justification of punitive or criminalising responses to self-harm and suicidality [264-267]. As Lucy Series describes, “[...] mental capacity law is being misused and abused as a way of rationing access to wanted support, and even to punish ‘bad behaviour’, based on a faulty legal logic that the duty to provide care and treatment and support for people experiencing significant distress and mental illness [...] hinges on ‘capacity’. Of course it doesn’t, in just the same way that treatment for a torn rotator cuff injury doesn’t turn on capacity assessment. All that capacity assessment should be for (in Anglo-Welsh law anyway) is what you do if you think that a person is unable to give or refuse consent to the treatment or support that you think the person needs.”[268]
When broken down, the phrase “you have the capacity to kill yourself” basically means “I have concluded that legally I can permit your suicide. I will not provide help to stop you killing yourself because it is your choice, and if you are asking for help because you don’t want to kill yourself, then you should just not kill yourself.” This is legally and clinically incorrect, unethical, and frankly, abhorrent. Being able to control and overcome suicidal urges does not necessarily align with decisional capacity. A person may feel totally trapped and overwhelmed by the need to end their unbearable pain and distress, but not actually want to die. Reaching out for help to stay safe and seeking support to bear the pain is what we are told to do. To then be faced by a professional who refuses that lifeline because they believe legally they are not compelled to help (therefore why should they bother) is such an appalling misuse of power, there aren’t even words. Having been on the receiving end of this myself, I can tell you that it was beyond devastating.
The purpose of the Mental Capacity Act is to protect people from medical paternalism and coercion, not to provide legal leverage for healthcare workers to withhold care from people presumed or assessed as having capacity. We do not have a healthcare system based on the exclusion of capacitous people. This is not a lawful use of the Act. As described by Alex Ruck Keene “capacity must never be used against the person” [269]. For capacitous people requesting crisis care when suicidal, the MCA does not stand in the way of healthcare professionals providing that care, no matter how capacitous the person is. For people lacking capacity who are requesting crisis care when suicidal, the MCA and the Mental Health Act (MHA) are at the disposal of healthcare professionals to provide care, if needed. For capacitous suicidal people who are refusing help, the MHA is available for healthcare professionals. For suicidal people both lacking capacity and refusing help, the MHA and MCA are available for healthcare professionals.
The Langley-Price report discusses cases where people labelled with personality disorder or personality disorder “traits” have received crisis plans from mental health services which included anticipatory declarations of capacity [270] - that is, a statement which predicts that the patient will always have capacity during future mental health crises. Once again, this is not a lawful use of the Act. While the MCA (and its associated Code of Practice) permits certain anticipatory declarations of capacity in people who have an ongoing condition which affects their ability to make certain decisions [271], it does not permit such declarations for people with fluctuating capacity (such as people with a mental health condition which causes periods of crisis), with the CoP stating: “As in any other situation, an assessment must only examine a person’s capacity to make a particular decision when it needs to be made.”[272] If mental health services wished to make a lawful anticipatory declaration for a patient with fluctuating capacity, this would need to go to the Court of Protection. Even with this, the declaration would only consider a lack of capacity, as nobody can decide that a person will always have capacity to make certain decisions in future situations, because we cannot predict the future and have absolutely no way of knowing what mental and physical state that person will be in at that time.
Earlier this year I published a study, exploring the emotional effect of hearing the phrase “you have the capacity to kill yourself”, and the consequences of subsequently having care withheld. Overall, the phrase was experienced negatively. 95% of people who took part in the study agreed that being told they "had the capacity to choose to kill themselves" made them feel worthless; 96% indicated that it increased their feelings of hopelessness; 84% said that it made them feel powerless; and 94% stated that it increased their suicidal feelings. It was not considered helpful, empowering, or compassionate, rather, it was experienced as abusive, traumatising and/or violent by many patients/survivors. 100% of respondents disagreed that it helped them recover from crisis, while 78% of respondents stated that it actually contributed to a subsequent suicide attempt. Many people interpreted the phrase as professional permission or even active encouragement to end their lives. Being told they had capacity frequently caused people to stop reaching out when suicidal and many described a partial or complete loss of trust in mental health services [273].
I am yet to read a piece of research regarding supporting suicidal people which has concluded that making the suicidal person feel more hopeless, worthless, and powerless is helpful, compassionate, or clinically effective.
Myth 14 - “BPD is a “behavioural” disorder” “It’s just behaviour”
Firstly, the infamous phrase “it’s just behaviour” needs to go in the bin. It has no meaning. Everything someone does is “behaviour”. Reading this is behaviour; having your morning shit is behaviour; going to work to tell distressed people that their behaviour is “just behaviour”, is behaviour.. In reality, the phrase “it’s behaviour” is code for “this expression of need or distress is not legitimate”. It is a marker for the “difficult” or undeserving patient [274-276]. It signals to other staff that this person can be neglected, derided, castigated, and dismissed, because the “behaviour” in question stems from a failure of character - a moral deviance - rather than an illness [277-281]. As reported by Stalker et al: “Another approach to personality disorder can be broadly described as behavioural. ‘Maladaptive’ behaviours, such as self‐harm, aggressive outbursts or social avoidance, are seen as learnt and able to be unlearnt. [...] people given this label are judged to be ‘morally irresponsible’ by some professionals.”[282]
Turning BPD into a conduct disorder is an active process of demedicalisation, which removes the person's rights under the sick role, as “mad”, and places them into the category of “bad” [283-286]. Patients labelled with BPD sit in a nether region - demedicalised and considered morally deviant, so they can be dismissed, while also carrying a psychiatric “disorder”, and thus remaining under the authority of mental health clinicians [287-288]. In this way, they are both owned and disowned. Mental health professionals can claim mastery over them, but hold no responsibility for their health or welfare. A recent study examining the impact of the BPD label on self-concept described how: “[patients] were simultaneously required to assume psychiatry’s accepted definitions of their health problems, whilst being told by the designated “healing” agents of this system, that they had, in fact, no health problems to resolve. As such, a typical [...] experience of mental health services was of being commanded to be ill, then accused of being well.” [289]
So-called “difficult” patients are frequently created by services based on staff perpetuated stigma, negative stereotypes, a lack of patient-centred care, negative staff attitudes, and the apparent “failure” of the patient to fulfil the desired role of the “good” patient [290-295](i.e a patient who is compliant, but not so compliant as to be considered dependent; openly grateful towards the staff without being obsequious; actively seeking out just enough care to be seen as engaging but not so much to be seen as attention-seeking; experiencing singular/non-complex difficulties that are either relatable to staff, and therefore not feared, or considered neurobiological in origin, therefore not the fault of the patient; recovering or progressing with treatment in a timeframe which is not so short that it appears suspicious, but not so long that staff become hopeless and despondent; and having endless understanding and patience for mistakes, poor care, abusive staff, discrimination, and unreasonable expectations from services.) [296-298]
Interestingly, with BPD, the “difficult” patient status follows the label, meaning whether or not the patient labelled as such actually displays the stereotypical “difficult” behaviours (attention-seeking, manipulation, malicious complaints etc), they will be perceived as doing so [299,300]. Research looking at staff responses to patient behaviour reports that staff perceive and judge the behaviour of patients labelled with BPD more negatively in comparison to patients without the label, even if their behaviour is identical [301,302]. Often this is related to the underlying belief of what is causing the behaviour, and whether this is felt to be under the control of the patient [303-305]. As described by Bowers, “The most common way in which this argument was articulated was for the nurse to say “they know what they are doing”. This point was made by many nurses, and their additional comments implied that the PD patients were not confused or muddled and were fully aware of what they did and the fact that it was wrong. Others voiced this argument differently, saying that PD patients were not ill and, more specifically, were not deluded or hallucinated.” [306] Staff describe feeling negatively, with higher levels of frustration and anger and lower levels of empathy, when they perceive the intent of patient behaviour is to be deliberately difficult [307-309].
This “difficult patient” status is so strong, staff who hold negative preconceptions regarding patients labelled with BPD have been found to behave in a discriminatory manner towards individuals, even before meeting them [310]. This leads to a self-fulfilling prophecy, known as the ‘expectancy effect’ [311]. The expectancy effect is a psychological phenomenon in which a person holding negative preconceptions about another person, changes their behaviour towards that person, which in turn causes the person to react in a way which reinforces the preconception [312,313]. For example, a mental health nurse believes and expects patients labelled with BPD to seek high levels of attention, therefore, when the nurse is assigned a patient with this label, they withhold attention, and respond coldly to attempts from the patient to make contact. The patient subsequently significantly increases their attempts to be seen and heard by the nurse. This “proves” to the nurse that the patient is attention-seeking, reinforcing their belief. Research confirms this process to be present in the interactions between mental health professionals and people labelled with BPD, contributing to negative clinical outcomes [314,315].
Very few people only have a diagnosis of BPD [316]. Studies looking at comorbidities find that almost all people labelled with BPD have at least one other mental health diagnosis, including: mood disorders - 96% (major depression, bipolar II, dysthymia); anxiety disorders - 88% (panic disorder, GAD, agoraphobia, OCD); eating disorders - 53-62% (anorexia nervosa, bulimia nervosa); dissociative disorders - 64% (dissociative amnesia, dissociative disorder NOS, dissociative identity disorder); and trauma- and stressor-related disorders - 56-61% (PTSD)[317-319]. However, even when displaying discrete and clear symptoms of specific diagnoses, people labelled with BPD are still frequently conceptualised as “acting out” or “performing” mental illnesses, not truly “suffering” from them like others [320] (see: myth 19 - Pseudo-psychosis). As discussed in the book, Feeding Anorexia, two people with identical physical symptoms could be diagnosed with anorexia, but the eating disorder in the one labelled with BPD may be felt by staff to be a form of bad behaviour related to BPD, while the person without the BPD label is seen as truly suffering from anorexia [321].
The perpetuation of the belief that people labelled with BPD are simply “badly behaved” continues to fuel discrimination and abuse within healthcare services [322]. When staff choose to perceive the needs, emotions, and behaviours of this patient group as a fundamentally manipulative means of gaining reward (sympathy, hospital admittance, medication etc), they are likely to (and do) respond with resentment, anger, cruelty, and neglect [323-325]. A study which explored nurses' perceptions of BPD found that “nurses had a strong sense that they were being manipulated by BPD patients. They associated BPD patients’ dishonesty with their manipulative behaviours. The idea that BPD patients are dishonest was linked to a general perception that they were not genuine. The participants frequently talked about there being an ‘agenda’ behind BPD patients’ interactions with them and trying to discover the real reason behind why they were doing something or wanting something.” [326] The framing of the distress and difficulties faced by people labelled with BPD as bad, manipulative, and dishonest behaviour creates the conditions in services for behaviour modification approaches to flourish. This includes handing out behaviour contracts which insist patients control their behaviour (self-harm, suicide attempts etc) or face discharge from services; the use of legal enforcements (criminal behaviour orders, community protection notices etc) to ensure patient behaviour doesn’t impact others (the public, emergency services etc); and even the use of custodial sentences to punish the “refusal” of patients to change their apparently wilful behaviour [327,328] “[Clinicians] think borderline [personality disorder] is more of a behavior problem or a discipline problem, rather than an actual psychological problem… that’s what they’re thinking,…that you can choose not to overdose or you can choose not to feel suicidal. I think that, you know, it’s upsetting. Because, you know, I don’t think one chooses to wake up one morning and say, “Gee, I think I’ll be suicidal today;... I think I’ll take a whole bunch of pills.” [329]
The ongoing debate about the mode of action of antidepressants, and psychiatry’s denouncement of the “chemical imbalance theory”, should theoretically be strengthening our collective understanding of the complexities of mental illness and psychological distress [330]. Realistically all mental health professionals should understand that mental health conditions cannot be neatly split into “biological”, therefore the person cannot control themselves, and “social/psychological”, therefore the person has full control over their emotions and behaviours. The public debates would have you believe this to be true, however, this nuanced understanding has yet to penetrate the wall of BPD stigma maintained by healthcare professionals. BPD is still very strictly seen as a social/psychological/behavioural issue, therefore all of its associated behaviours are deliberate and under the control of the person, legitimising the abusive behaviour of staff.
Myth 15 - “You can diagnose BPD based on how you feel when you interact with the patient”
The myth that staff can “diagnose” BPD based on their emotional reaction or the response of services towards a patient would be laughable if it didn’t actually occur, and leave people dealing with the very real and often devastating consequences of a personality disorder diagnosis. Not only does this practice have absolutely no evidence to support it, it also creates situations where staff are authorised and even encouraged to have zero emotional insight or responsibility for their emotional reactions, as they can “legitimately” blame all their negative feelings and behaviours on their patients. This practice is so widespread and accepted it even appears in a Department of Health document [331]: “How do I recognise when someone has personality disorder? [...] Something unusual in how you or the service responds to this individual. Sometimes it is our own reactions, or the response of our colleagues or our agency to an individual [..] [which] signals that this service user has personality difficulties” Some of the suggested “unusual” responses include: “Forgetting about them or feeling reluctant to engage with them”, “Making an exception and offering them special treatment”, “Finding yourself responding less sympathetically than usual”, and “Feeling useless and as though you have nothing to offer”... Somehow, incredibly, mental health professionals have convinced themselves and healthcare commissioners/regulators that if staff mistreat, ignore, dismiss, lack empathy for, over empathise with, or don’t know how to help someone, that person has a disordered personality.
The clinical term for this process is “countertransference” or “countertransference diagnosing”. The concept of “countertransference” was first proposed by Freud in 1910 as a description of the emotional reaction therapists have towards their clients within psychoanalytic therapy [332]. Just as “transference” is understood as the process by which clients project their internal world onto their therapist, countertransference was initially proposed as the same process, but from the therapist towards the client; the therapist unconsciously experiencing their client as someone from their own past, bringing to the surface their own unresolved feelings and conflicts [333]. Freud believed countertransference within a therapeutic setting was “a personal problem for the analyst”, something for therapists to overcome with their own therapy [334]. However, building on Freud's theory, over time the concept of countertransference expanded from emotions based on the internal world of the therapist, to include a second type of countertransference in which the emotions experienced by the therapist indicated something about the patient and the patient’s internal world [335]. If properly recognised and understood, transference and countertransference is believed to be useful or an important aspect of the therapeutic process between therapist and client [336], however, within modern day mental health services, the concept of countertransference is misappropriated, misunderstood, and used as a catch-all term for the emotional response of any and all staff members towards patients, often with the total absence of any reflection or acknowledgement of the professional’s internal world, their biases, prejudices, difficulties, lack of professional skills, and poor emotional resilience.
In practice, countertransference is commonly used as a means of blaming or placing responsibility for staff members' emotions onto patients, who are often suggested to have deliberately elicited specific emotional reactions in staff [337,338]. A paper discussing BPD countertransference in emergency medicine describes patients labelled with BPD as having “an uncanny ability to focus in on our vulnerabilities”, knowing which buttons to push to elicit a reaction in staff [339]. It goes on to describe how in the case of the “attractive and needy” patient, staff may fantasise about rescue, while in those who are not attractive, staff may experience feelings of anger and revenge. Similarly to “splitting” (see myth 16), countertransference is concept utilised by mental health staff to avoid taking any responsibility for their own emotions, team dynamics, or working environment, and actively promotes the idea that staff do not need to reflect or work on their negative emotions, as they are simply helpless empty vessels, filled with the emotions of their patients. The extract below is one of the most shocking examples of this that I came across. Please read with caution, it contains a graphic description of an imagined physical assault/murder of a patient by a psychiatrist. (The underlining highlights how many times the author assigns responsibility for the clinician’s emotions to the patient)
“It is nevertheless a clinical commonplace that primitive patients call up emotional responses and fantasies potentially so shocking they are repressed or, should they rise to consciousness, give rise to shame. These reactions can lead to serious therapeutic misadventures including patient abandonment and suicide. A psychiatric resident was assigned a chronically suicidal borderline woman whose accelerating self-gashing was generating great anxiety and counterhostility in the inpatient staff. He found the long interviews in which she refused to speak to him excruciatingly painful, but he did not grasp how much hostility she aroused in him. After some weeks, in yet another seemingly interminable session he was staggered and horrified to experience a vivid, intrusive fantasy of cutting the patient's throat so deeply that blood spurted from the severed arteries. He was so distressed that remaining in the room was almost impossible as he fought back tears. The support of an empathic supervisor helped him understand that this response was being generated in him by what the patient was doing; he experienced her escalating self-mutilation as a personal assault, he felt helpless, and had experienced a primitive retaliatory sadistic fantasy as a result. He learned that the sadistic fantasy and impulse she generated in him represented a component of the patient's inner life that she could not tolerate and was extending into the environment around her.” [340]
The encouragement of the “countertransference diagnosis” of BPD, a practice in which staff use their angry, vengeful, fearful, frustrated, difficult, or unexpected feelings about a patient to diagnose them with a personality disorder, is deeply concerning, indicating that staff believe they all have the same objective reactions to the same patients. Some authors warn against this, with one stating: “There is an ever‐present risk that the therapist may confuse his/her own feelings with those of the patient. It is important to clarify in this context that the countertransference jointly created by patient and doctor will vary from one clinician to the next. The therapist's experience of important people in his/her life has also been internalized and interacts with whatever is projected into him/her by the patient. Hence, there are variations from one therapist to another depending on how the combination of the patient's projection and the therapist's internal world interact.” [341] The implication of diagnosing based on countertransference is that simply by being mental health professionals, their emotions and how they interact with the patient’s emotions are not related to their own internal world, everyday stressors, relational and trauma history, position of power, mental and physical health, etc., but are objective diagnostic tools. Mental health professionals interviewed within studies give numerous disgusting descriptions for this “objective” countertransference feeling. A therapist working at an eating disorder clinic described the experience of “encountering” a “borderline” as "like encountering those Dementors in Harry Potter” [342]. A psychiatrist dubbed it the “meat grinder sensation”, stating “if you are talking to a patient and it feels like your internal organs are turning into hamburger meat she is probably borderline” [343]. Another psychiatrist described how “borderline” patients present like “Dickensian orphaned waifs [with a] peculiar ability to inflict a specific form of “sweet suffering” on their therapists.” [344] Not exactly what you would expect from a rigorous scientific diagnostic method. Concerningly, nobody seems to have thought that labelling a patient with the most stigmatised psychiatric diagnosis in existence simply because you don’t like them or feel annoyed, angry, disgusted, tired, unsupported, worried, or unsympathetic when interacting with them, leaves patients in an extremely dangerous situation, whereby if they do not do everything possible to ensure staff like them, they may face a BPD diagnosis in retaliation. That is not a safe environment for vulnerable people and can even be experienced as a replication of abuse: “[Within services] every moment of every interaction is a chance for staff to judge, record, and diagnose you… over and over again. Every single thing you do and say in their presence [...] even one moment of annoyance or frustration or anger or despair, or just misspeaking, can tarnish your entire future under services. It is exactly like being in an abusive relationship – watching your every word, ensuring every action is calculated to keep the other person happy. Knowing if you slip up, you’ll be made to pay.”[345] Further to the risk of re-traumatisation, is the risk of mental health professionals using the concept to dismiss legitimate complaints, excuse their negative emotional reactions, and side step their professional responsibilities [346,347]. Clinicians unable to effectively manage their own emotions can end up ignoring or minimising the patient’s risk of injury or death from self-harm or suicide, withdrawing from the patient in defence [348]. In her book Cognitive Behavioral Therapy of Borderline Personality Disorder, Marsha Linehan explains that it is “extraordinarily easy” for clinicians to enact their vindictiveness and hostility towards patients, punishing them covertly by numerous supposedly “therapeutic” means, including withholding care; sectioning; over or under medicating; discharging; writing pejorative case notes; and making invalidating appeals to unconscious motivations [349].
Examining who is made to carry the BPD label is crucial when attempting to understand staff-patient interactions. People most likely to be labelled with BPD are young women, people within the LGBTQ+ community, people who have experienced complex and severe interpersonal trauma, Autistic people, people with ADHD, and long-term users of mental health services (particularly those who self-harm and/or attempt suicide frequently) [350-354]. Overall this is a population likely to have experience of chronic disempowerment/relational powerlessness, prejudice, discrimination, abuse, and iatrogenic harm. When people can be “diagnosed” with BPD based simply on how staff feel when they interact, it is not surprising the above group are the people most commonly captured by the label: a group filled with people research consistently finds to be judged negatively, disliked, discriminated against, and avoided by healthcare professionals. For example:
Autism: Research finds autistic people are more vulnerable to being judged negatively than neurotypical people, including being incorrectly perceived as “more deceptive” and “less credible” [355]. Neurotypical people are reluctant to pursue interactions with autistic people and view them less favourably in terms of likeability and attractiveness [356]. Autistic people are also more frequently the victims of bullying, ostracism, and relational aggression than their neurotypical peers [357-359]. Autistic communication styles, including literalism, honesty, situation mutism, unusual tone/volume of speech, and unemotional descriptions of difficult topics have been suggested to be interpreted as manipulative, game-playing, dishonest, and aggressive by mental health clinicians [360].
Trauma: Patients labelled with BPD are extremely likely to have a past history of trauma, up to 92% will have experienced sexual violence, neglect, or emotional/physical abuse [361-362]. A large amount of research indicates that staff are often uncomfortable with the subject, choosing to avoid or minimise exposure to details of patients’ trauma due to feeling afraid, not knowing what to say, being preoccupied with the extra paperwork they may need to complete, and being concerned they will be traumatised by what they hear [363-367]. Literature from the 1980’s describing countertransference reactions in therapy with Vietnam veterans found numerous emotional difficulties experienced by therapists, including the inability to emotionally connect with patients; the deliberate avoidance of thinking or talking about Vietnam, including steering patients away from the topic; and judging patients from a moral perspective for their involvement in violence [368]. Some therapists refused to consider the trauma soldiers experienced in Vietnam, and insisted that combat had simply revealed underlying pathologies, including borderline and narcissistic personality disorder [369]. Similar responses can be seen in clinicians interacting with patients who have particularly upsetting trauma histories, such as child sexual abuse. Clinicians may find themselves over-identifying with patients, feeling powerless, fearful and wanting to avoid the subject of abuse, or identifying with the patient’s abuser, reacting negatively at the patient’s expression of anger or blame, and focusing on the patient “taking responsibility” for the part they apparently played in the abuse [370]. Personal discomfort in these situations is very important to note, as it has the ability to negatively affect patient care and the choice of diagnosis. As described by Nixon and Quinlan, “[increased avoidance of sensitive topics can] lead to therapists prematurely concluding assessments, which may increase their reliance on initial impressions and make them susceptible to confirmatory bias, leading to inaccurate formulations.” [371,372]
Self-harm and suicide - Healthcare services which support suicidal people and people who self-harm are at risk of providing unhelpful and potentially counterproductive responses if staff are unable to regulate their emotions appropriately [373]. When working with suicidal patients and patients who self-harm, clinicians frequently experience a range of negative emotions, including anger, frustration, fear, self-doubt, guilt, anxiety, powerlessness, and irritation, and may respond with resentment towards their clinical responsibilities; avoidance; denial; the desire to withhold care or use overly restrictive practices; and negative or discriminatory attitudes and behaviours[374-382].
Patients falling into any of these groups face the very high risk of being perceived negatively by mental health professionals, and subsequently labelled with BPD simply because the clinician felt a difficult or uncomfortable emotion.
Within research, it is commonly agreed and accepted that the quality of relationships and interactions between staff and patients is central to care being experienced positively[383-387]. Where staff are able to cultivate and maintain positive relationships, including providing caring, consistent, and proactive responses; showing genuine interest in patient’s lives; and being optimistic about recovery, patients are more likely to have reduced risk and increased well-being [388-392]. Staff indulging and excusing negative thoughts and emotions about patients (refusing to reflect on their own internal worlds) obstruct therapeutic relationships and interventions. As discussed by Linn-Walton and Pardasani, “One of the clinician-related factors that can affect treatment outcome is countertransference, specifically the issue of disliking one’s client.”[393] Patients are able to recognise reduced empathy, dislike, and rejecting behaviours in staff and react accordingly, losing trust, withdrawing from staff, and self-harming with greater frequency [394-398]. Once BPD is floated, the patient is permanently labelled, which, as described by Treloar, may negatively impact every subsequent interaction with mental health services: “The observation that many professionals decline service to patients with BPD, and are unable to provide an objective assessment based on the presence of BPD as a diagnosis, were supported by many clinician responses: “Once labelled as BPD it is hard for the patient to be given an objective assessment…”.”[399]
Given that BPD has 256 different diagnosable presentations and is almost always diagnosed alongside multiple other mental health conditions, it seems the only thing clinicians can agree that all people labelled with BPD have in common is that professionals dislike them. Despite this, clinicians continue to encourage and legitimise the diagnosing of BPD based on staff feelings, rather than admitting they have created a label simply to apply to patients they dislike. As commented by a clinician: “I have found people with BPD to be manipulative and I wonder if BPD is just an excuse for bad behaviour and nastiness” [400], I also wonder if BPD is just an excuse for bad behaviour and nastiness. Except, from my perspective, the bad behaviour and nastiness emanates from healthcare professionals towards the people they have labelled with BPD.
Myth 16 - “Patients with BPD play games with staff to deliberately split the team”
“Splitting the team” or “staff splitting” in services refers to poor team dynamics, in which members of the same clinical team hold (sometimes drastically) different opinions about an individual patient and their care. Often this includes some staff holding positive opinions and feelings about the patient, while other staff hold negative opinions and feelings, forming two opposing camps. Unfortunately, instead of staff reflecting on their own emotions and thought processes, and working through difficult feelings, the patient is blamed for “causing” the team’s dysfunction [401]. The psychoanalytic understanding of the process of splitting asserts that the BPD labelled patient engages in an intrapsychic defence mechanism when interacting with staff, in which they consider individual staff members either all good or all bad (known as splitting or black and white thinking) [402]. The different interactions between the patient and the “good” staff and “bad” staff subsequently cause staff to hold differing opinions and feelings of the patient which (magically) creates huge problems within the (apparently previously functional) team. As described by Woollaston and Hixenbaugh: “One [camp] consisting of staff members who were sympathetic towards a BPD patient and another made up of staff who disliked the same patient. This division resulted in the former camp describing the other as ‘over-involved’, while this camp criticized the other for being harsh and uncaring. In the following extracts, nurses describe this process: ‘Some people will see the emotional needs of the client, other people will see the behaviours that they are displaying... those normally seem to be the two camps. I think the manipulation… the classic thing here about trying to split the staff team...it seemed to be some sort of game aimed at getting control of certain elements of the staff team’.” [403]
In literature published between 1950-1970, the phenomenon of splitting is frequently discussed and described as a process contributed to by both patient and staff. Unresolved or poorly managed personal and professional issues in staff; ongoing team disagreements and conflicts including latent splits amongst staff; staff competitiveness; and disharmony within the hospital are all considered to contribute or create the problem to which the patient falls victim and then helps maintain through their emotional response to the situation [404-407]. From the late 1970’s onwards, the literature begins to reflect a more individualised perception of team splitting, in which the patient is to blame for externalising an internal conflict and manipulating the staff to act this conflict out [408]. In this new understanding of splitting, staff become the inert, helpless victims of the patient. As one author describes, “staff are left not only to pick up the pieces but also feeling in pieces. As recipients of the good and bad part-object projections of the borderline patient, the staff becomes a collective representation of the patient.” [409] The term “Main’s Syndrome” was even coined by one author to describe a clinical syndrome characterised by splitting in “manipulative” “hysterical” patients. Main’s syndrome was suggested to cause those who came into contact with the affected person to have strong emotional reactions, including the desire to take “excessive” and “irrational” measures to rescue them [410].
Patient and survivor accounts of how the concept of “splitting” is currently used in services are not very common. The Langley-Price report briefly focuses on how staff use the concept of splitting as a means of dismissing patient complaints, including two pieces of patient testimony. The first describes a person’s experience of having a serious complaint about sexual abuse by a staff member quashed, as it was described by staff as an attempt by the patient to split the team. The other is a description of how complaints from patients labelled with BPD are dismissed as a “deliberate [attempt] to split the team and make [staff] fight” [411]. The critical theorist and activist collective, Recovery in the Bin, have two published pieces which describe splitting, one of which satirically warns mental health patients not to like some staff members more than others, or they are at risk of being diagnosed with BPD [412], and another which breaks down myths and facts, describing how “the concept of splitting was originally about how the most vulnerable patients could be caught up in the dynamics of weak, fractious teams. Overtime, and unsurprisingly given the problematic staff in such teams, splitting has come to be a phenomena blamed on the patient. In family therapy dynamics like this where dysfunctional parents blame the child would be called ‘scapegoating’.” [413]
Within services the term “splitting” appears to be used as a casual form of shorthand by staff to imply a patient has a personality disorder; to indicate a patient is manipulative or “difficult”; to externalise the personal emotional difficulties of individual staff; to create a clinical explanation which places responsibility for staff problems onto patients; to indicate a personal dislike of a patient; to dismiss complaints; and to excuse poor practice and abusive staff behaviour [414-417]. As described by Green, “I have seen situations where the identification of splitting takes on the quality of an accusation, and seems to function to absolve staff of any responsibility they have for being kind or thoughtful. I have even seen instances of frank cruelty by staff that are later explained away as being produced by the patient through their splitting.” [418] Ironically, given that DBT is frequently criticised as blaming patients for wider societal and service problems [419], Marsha Linehan discusses “staff splitting” from the perspective of DBT, stating that blaming the patient blames a person or an external event for a problem staff are having, a type of thinking DBT attempts to challenge [420]. She remarks, “the staff splits the staff”. This view is echoed by Catherine Allen, who writes that “resource limitations may also shape service responses [...] The process of blaming the person with a BPD diagnosis for ‘splitting the team’, when multidisciplinary teams are so often riven with unacknowledged power battles and disagreements, is a common example.” [421]
It is much easier to blame a patient or a group of patients for personal and professional reactions, disputes, and dysfunction, than to recognise and respond to team conflict and personal emotional difficulties [422], particularly when blame can fall on a patient group staff seem to derive so much pleasure from hating.
Myth 17 - “No amount of care will ever be enough for someone with BPD” “They have unrealistic expectations of care” “They feel they are owed care”
This is a particularly hideous myth, which in numerous different ways indicates that people labelled with BPD have an unquenchable desire for care that they do not need/deserve, and no matter how much staff try and satisfy this need, these patients will continue to demand more and more and more, until staff (painted as the victims) break under the pressure. As one paper writes, patients labelled with BPD commonly present with “an offensive sense of deservedness”[423]; another states how “deservedness and entitlement underscore the narcissistic core that causes these patients to demand immediate relief of anxiety” [424]; while another describes a “repugnant” entitlement to care [425], stating: “The entitlement of the patient is particularly hard for the staff to bear. Their first impulse is to be generous toward the patient: after all, giving is a comfortable role. But after a while the demands become intolerable and cause hatred. This hatred may be denied until a breaking point is reached in which entitlement is confronted suddenly and devastatingly. [...] [It] is important to avoid a confrontation in which the patient is told that the care is not deserved but a gift, and an unwilling gift at that. Entitlement is the borderline patient’s religion and must not be confronted blasphemously.”[426]
It is hard to reconcile how this patient group could be perceived by staff as so intensely entitled, demanding, and deserving of special treatment that staff actually feel hatred towards them, while research consistently finds that people with this label have a chronic negative self-concept, experiencing significantly higher levels of self-loathing, self-hatred, self-disgust, shame, guilt, self-contempt and self-revulsion in comparison to “healthy” participants; are highly self-critical; report high levels of feelings of inferiority to others, including feeling unworthy of love and attention and unworthy of mental health care; and frequently consider themselves unlovable, deserving of punishment, incompetent, fundamentally flawed, and as less than human [427-432]. Not exactly a cohort you would expect to be brimming with “offensive deservedness” and a “repugnant” entitlement to care.
Staff may believe they are “giving and giving” mountains of care to patients who will never feel it is enough [433], but survivor testimony, academic research, and crumbling underfunded NHS services suggest that staff perception is incorrect, and patients labelled with BPD frequently experience discrimination and exclusion. As described by Sulzer, “the denial of treatment to patients with BPD is a pattern that has been consistently found in the literature and has not been logically linked to the actual ability to provide treatment” [434]. Common themes running through the experiences of many people under services with a BPD diagnosis include neglect, exclusion from care, the withholding of care, a lack of appropriate care, a lack of trauma, psychosis and eating disorder treatment, the refusal to provide adjustments for or recognise autism and ADHD, abusive and discriminatory staff behaviour, complaints being automatically dismissed, overly restrictive practices, long-term out of area restrictive hospital placements, being over or under medicated, and being subject to criminal sanctions for apparent “high service use” or public distress [435-461]. People may call crisis services, their GP, or present at A&E frequently due to self-harm, suicide attempts, or being in crisis, but this does not constitute appropriate long-term care. Other things which do not constitute care: waiting lists, psychological or psychiatric assessment, self-help workbooks, being signposted to 3rd sector organisations such as the Samaritans, being told to take responsibility, being repeatedly referred and rejected from services, being told suicide is a choice, being bounced between services, and being under services (including community, hospital and crisis teams) but being mistreated or neglected. As described by a Recovery in the Bin blogger: “[Mental health] services are underfunded and under-resourced. People with severe illnesses that should have intense community support are considered to receive a lot of support if they see a key worker for 1 hour a week – that’s 1/168 hours. Most clients have even less input. Rather than owning this many staff accuse patients of being overly demanding and perceive them as taking up their time. When staff position themselves as victims doing all they can to rescue and care for an accusatory client they really are losing the plot and failing to see the situation objectively: they feel overworked and patients are rightly identifying insufficient services.” [462]
The NHS exists to provide us with care when we need it. It is not free. It is a state provided service, paid for by our taxes. We do not need to grovel, feel indebted, as if we are being done a favour, or being “gifted” something when seeking care. As stated by the NHS Constitution: “The NHS belongs to the people. It is there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can to the end of our lives” [463]. Being upset about not being provided with timely and appropriate care is not inappropriate, demanding, or wrong in any way. We have a legal right to care when we need it. Suggesting that people who expect to receive a high standard of appropriate medical care when in need, are somehow grasping, entitled, demanding, or holding unrealistic expectations, is to fundamentally misunderstand the role, ethos, and duties of the NHS and its staff. Further to that, believing that patients labelled with BPD generally receive a high standard of appropriate care but are simply ungrateful and chronically unsatisfied, is to ignore the mountains of evidence to the contrary [464].
The majority of people with a BPD label have experienced trauma, such as childhood abuse, neglect, and sexual violence [465,466]. The emotional and psychological fallout following such experiences cannot be solved with 6 sessions of CBT, or an online DBT skills course[467]. I would be surprised if anyone felt they had been given an appropriate amount of support after that. Many people don’t even get the bare minimum, but are discharged or barred from accessing services altogether[468]. In 2018, NHS England announced that victims of sexual abuse would receive a “lifetime of mental health care” to help cope with their trauma. Kate Davies, NHS England Director of Sexual Assault Services, stated: “The physical and emotional impact of sexual crimes lasts a lifetime, so it’s important that survivors can get the help they need, whenever they need it.” [469] Apparently this announcement did not make it to mental health professionals on the ground, who continue to suggest that expecting anything more than neglect is unreasonably demanding and entitled.
In reality, it seems likely that staff perceive patients labelled with BPD to be demanding and chronically unsatisfied because they have normalised under-resourced, underfunded, under-staffed services; normalised dismissing patients with little to no care; normalised projecting their feelings of inadequacy and helplessness onto patients; and cultivated a culture in which it is entirely appropriate to use BPD labelled patients as scapegoats for absolutely every problem encountered in services [470-477]. In their 2020 position statement on personality disorder, the Royal College of Psychiatrists state: “[...] unsupported staff will fear and avoid the necessary emotional contact, work defensively and too often declare patients un-engageable or untreatable. In non-specialist settings, the consequences of this can be interventions which represent retreat into simplistic impersonal solutions (such as a reactive prescription of medication), punitive reactions (such as seclusion or arrest), referral to services with higher levels of physical containment or expulsion from services altogether.”[478]
Since the inception of the BPD diagnosis, mental health services and professionals have consistently done everything in their power to not treat patients they have forced to carry the label. As described by clinicians in a study of emergency and mental health service experiences of working with BPD labelled patients: ““the health service provides inadequate care”, “[patients labelled with BPD] are neglected by mental health services”, and “some professionals refuse to treat them”.” [479] If patients are making desperate attempts to seek care, perhaps before characterising them as entitled, demanding, and unreasonable, staff should consider whether they have ever received any form of meaningful, appropriate, long-term treatment - because the answer will likely be no.
Myth 18 - “Making a complaint about services is a sign of BPD”
The idea that people who make complaints about mental health service provision are ‘personality disordered’, is quite possibly the most self-serving of all the myths, and, amongst other things, breaches patients’ statutory rights to have complaints heard [480,481]; contravenes the NHS pledge that complaints against services will not adversely affect the complainants future care [482]; makes a mockery of claims of informed consent; and has the capacity to cover the tracks of sexual predators and other dangerous personnel in services [483]. As described by Hook and Devereux, “The reluctance of the professions to engage with patients' perspectives is disappointing because patients have been publishing detailed accounts of harm for decades. Professionals' responses to such accounts are frequently dismissive, disrespectful and frankly abusive. Patients who make complaints about sexual boundary violations similarly find themselves disbelieved or diagnosed with new conditions such as borderline personality disorder or erotomania. Indeed, it is not uncommon for them to subsequently find that the events are described in their notes as ‘delusional’ and that they are referred to as ‘serial complainers’.” [484,485]
Complaints from people labelled with BPD are often perceived by mental health staff as manipulative/malicious/coercive; a symptom of interpersonal difficulties; a form of therapy- or system-“interfering” behaviour; a means of undermining or targeting staff; an attempt to avoid responsibility or consequences; an attempt to stop working with particular staff; or evidence in support of “difficult” patient status [486-491]. In clinical practice, staff commonly feel deeply concerned or even afraid of potential patient complaints against themselves [492-494], which can lead to defensive behaviours, such as changing practice to avoid complaints or discrediting complainants [495,496]. In avoidance of complaints, staff may elect to change their practice, including refusing to see apparently “high-risk”, “difficult” or “complex” patients [497]. To discredit complainants, staff may cultivate and share new “truths” about individual patients, or patient groups, which predict vindictive litigious behaviour - such as complaints being a defining feature of BPD [498,499]. In this way, the patient is not only discredited before they ever make a complaint, but the action of complaining works to confirm their labelling as personality disordered [500,501].
There is a total lack of evidence in support of the myth that patient complaints are associated with personality disorder, rather, this narrative often appears to arise from feelings of defensiveness or incredulity in staff, and an unwillingness to reflect on their own behaviour or failures in service provision [502-505]. “In psychotherapy, patients are usually seen as having been victims of neglect or abuse and deserving of help. This can rapidly change in the professional's mind when the patient complains. At a recent workshop on learning from patients’ complaints, organised by a national psychotherapy regulator, an ethics committee member asserted that patients who make complaints have borderline personality disorder. This appeared to be eagerly believed by other delegates, despite an absence of research confirming the statement. Similarly, a delegate, with an apparent grievance, asked that complaints be analysed within the therapy, implying that therapists should not have to defend their actions.” [506] While complaints being a symptom of BPD is fictitious, the abuse, discrimination and neglect from healthcare professionals, described by people labelled with BPD, is not. There is a wealth of literature documenting the appalling treatment from healthcare professionals directed at people labelled with BPD, people perceived to fit the BPD clinical stereotype, and people with supposed “BPD traits'' [507-526]. Despite this very real academic understanding of the types of attitudes and mistreatment the label brings with it, a practical understanding hasn’t yet caught up with how staff and patients interact in services. Patients not working well with some staff, patients stating that they are not receiving proper care, patients making formal complaints about staff or services, patients speaking out about abuse and discrimination are still viewed as the problem, as “typical borderlines”, as having interpersonal issues, as making malicious complaints. Professionals rarely seem to stop and put two and two together. Maybe patients are reacting to the torrent of documented abuse, discrimination, neglect, and even hatred, from healthcare professionals involved in their care.
The refusal to see complaints as anything other than a symptom of personality disorder is described by Veysey as “powerfully silencing” [527]. This is also reiterated by the Crown Prosecution Service in their psychological evidence toolkit: ‘Individuals have reported that there is, at times, an automatic disbelief from others about their experiences, once again derived from the stereotypical view of people with [personality] disorders. The idea that making complaints is typical behaviour for someone with a personality disorder diagnosis can be a powerfully silencing one – with the individual drawing on past experiences of not being believed or listened to. Complaining can often be viewed as manipulative behaviour and this can have a negative effect on the persons willingness to proceed with their complaint.’ [528] The silencing of complaints is not just dangerous for individuals experiencing poor care, but also fails to recognise the importance of patient complaints in the development and maintenance of safe and effective healthcare environments [529-532]. Research finds that patient complaints about staff and services contain useful information on how services can be improved and can act as early warning signs of systemic failures [533,534]. The majority of patient complaints are found to be valid, and have been described as “robust, distinctive indicators of health care quality” [535-537].
The absolute injustice of the BPD label is highlighted so succinctly with this myth. Once labelled with BPD, everything the person says, does, thinks and feels can be twisted to reinforce the application of the label. The person is incapable of moving without becoming more tightly constricted. The longer this occurs, the more humanity, credibility, power, and autonomy is stripped away from the person, and the more vulnerable they become to clinical negligence, mistreatment, and abuse. The tighter and more constricting this becomes, the more likely the person is to complain, which (as an apparent “symptom” of BPD) simply constricts them further. All actions the person may take to untangle and free themselves can be used to further entrap them. As described by Langley and Price, “This inescapable, self-fulfilling cycle of diagnostic entrapment silences the voices of those patients caught within, effectively ensuring legitimate complaints about ineffectual, negligent, or abusive services/staff are not taken seriously. It also renders BPD-labelled patients more vulnerable to further abuses, with staff well aware that their word will always be believed over someone consigned to this diagnostic hellscape.” [538]
Myth 19 - “Voice hearing, hallucinations, delusions and other similar experiences are pseudo/quasi/fake/transient in people with BPD - not real psychosis”
Between 20-50% of people labelled with BPD describe experiencing symptoms of psychosis, including auditory/visual hallucinations, and paranoid delusions [539,540]. Despite a long and well documented history of psychosis and psychotic experiences in this patient population, diagnostic criteria for BPD only includes “transient, stress-related paranoid ideation” instead of psychosis [541]. Symptoms of psychosis in patients labelled with BPD are frequently dismissed as “pseudo”, “quasi”, “transient”, or even “malingering”/faked; a judgement which often appears based only on the label of BPD [542-544]. People who have had their diagnosis changed from BPD to a psychotic disorder, or vice versa, report experiencing a change in how their psychosis is conceptualised, seemingly based solely on their diagnosis [545].
Recent research attempting to dispel the myth of BPD “pseudo/quasi” psychosis finds that psychotic experiences in BPD labelled patients show more similarities than differences to psychotic experiences in people diagnosed with psychotic disorders; can be prolonged rather than transient; are not limited to stress-related paranoid ideation; and the current clinical understanding is not consistent with patient experience [546,547]. Some clinicians also note seeing significant similarities between psychotic experiences in patients labelled with BPD and those with psychotic disorders, with a psychiatrist and mental health nurse stating: “In clinical practice we were seeing frank psychotic symptoms that in some cases were severe and enduring. It appeared difficult to distinguish these psychotic symptoms from those in people diagnosed with functional mental illness.” It has been suggested that childhood trauma and PTSD may play an important role in the development of psychosis in people labelled with BPD, with hallucinations being specifically associated with sexual and physical abuse [548,549], but this area is under researched [550].
Diagnostic criteria describe psychotic experiences in BPD as being stress related. However, while symptoms such as auditory hallucinations do increase due to a high degree of stress in people labelled with BPD, this is actually found to be the case for all people with psychotic disorders[551]. Terms like pseudo-psychotic and quasi-psychotic are a misleading, pejorative, “disrespectful myth” which add to stigma, and clinicians are urged by researchers to avoid them [552,553].
Once again, people labelled with BPD are side-lined by mental health professionals, and have their difficult and distressing experiences downplayed, invalidated, and reconceptualised as less serious, less genuine, and even faked for some kind of reward - with no evidence to support this belief.
Conclusion
I have not written a long conclusion here, but instead, left you with the words of two friends who were mislabelled with BPD, and subsequently endured years of abusive care and neglect from mental health and social care services. Zoe Zaremba and Fern Foster both ended their lives in the summer of 2020, within weeks of one another. They were my friends. They had so much more life to live, so much more to show the world, so much more kindness to experience. They should still be here. They are missed.
“Imagine that you read something written about you that you find to be offensive, untrue, misleading, hurtful etc. and yet when you try to raise these feelings with the person who made such comments they simply dismissed them as your perception, your unsubstantiated self-generated thoughts, you lacking insight into yourself, a symptom of your personality being disordered. How would that make you feel? Would you feel trusting towards this person? Would you feel heard, respected, and understood? Would you want to work with them closely and discuss intimate aspects of your health with them? Would you want them to describe you to others in your life without you knowing or agreeing with their version of you? I think the logical answer to the majority of those questions for most people would be no, and yet in the context of personality disorder and mental health services, this is often not an acceptable response to clinicians. In my personal experience, if you dare to push the point that you don’t want to work with such a clinician, then you are splitting, refusing to engage, you have trust issues, you have relationship issues etc. You are discredited and invalidated a second time! Because YOU and YOUR REACTIONS are the problem, never what they wrote about you. Can’t you see that? This scenario can repeat over and over, grinding you down. And yet, your response is actually perfectly natural and most human beings (certainly the ones I know) would have exactly the same response, including the very professionals who claim that these responses are unacceptable. But, I guess they are the ones that get to give out the labels, not have them applied to themselves, and that's what separates us. I really think they need to learn to reflect on their practices by putting themselves in their patients shoes (e.g. as above), and then maybe, just maybe, they might see why their actions can be so harmful and soul destroying.” [554]
- Zoe “AspieZ” Zaremba
“Mental health services are the ultimate gaslighters. Once you have spent a long time under their care, you can lose your sense of self and start to constantly doubt your own perceptions and behaviour. Sometimes I don’t know who I am outside of their view of me. I second-guess myself, ask “am I just doing this because I am an attention-seeker?”, even if attention is the last thing I want. It’s impossible to explain the extent of the harm to someone who hasn’t experienced it. The sense of worthlessness and self-hatred it creates. It kills people.” [555]
- Fern “Elyssa” Foster
References
Unfortunately the blog post got too big to include the hundreds of references, so they got their own blog post, here.