Wednesday, August 8, 2012

Ask Haven: How do you tell someone they might be Borderline?


A question I receive often from people concerning loved one’s is:


How can I tell [someone I care about] that they might have Borderline Personality Disorder?



The answer is simple. You don’t. Unless you are a licensed clinician, therapist, psychologist, or psychiatrist; don’t do it. You haven’t been trained to assess people’s mental health. You especially haven’t been trained to judge the mental health of someone you don’t have an objective perspective of. I know it’s very tempting to look at the qualifications of the DSM and check off the similarities in your mind and come to a conclusion on your own. You may even be right. But that doesn’t mean you should try to give someone a diagnosis.

I understand the desire for your loved one to behave better and feel better. But even if you are correct in your assessment, you shouldn’t label them yourself. That doesn’t mean you shouldn’t DO anything though. You can, and probably should, gently encourage your potential Borderline to seek therapy and counseling.

But if they do have Borderline Personality Disorder, why shouldn’t you say something?

Because you may be doing more harm than good.

First, ask yourself this: Are you so intent on the diagnosis for their good, or for yours? Will it bring you closure to hear your loved one has this as the issue? Or are you solely concerned with their mental well-being?

Many therapists may recognize BPD when they see it, which may occur years before a formal diagnosis is given. More importantly; they also have a healthy fear of diagnosing it, due to it being counterproductive to whatever modality of treatment they are applying. Telling someone they are Borderline before they’re ready to hear the diagnosis can be detrimental and even set back their healing.

For the therapeutic process to work the patient needs to be ready, willing, and able to work with their clinician. Borderline Personality Disorder is highly stigmatized. Most people don’t want to hear that there is definitively something wrong with them. It can feel like an attack, an accusation and the ultimate rejection. Rejection of sanity, rejection of validity, rejection of basic functioning humanity. Forcing a diagnosis on someone who is not ready to hear it can easily make them reject the diagnosis, and therefore reject therapy. If a person rejects therapy, they can’t be helped. You can’t help an empty chair. Many people are afraid to be diagnosed with a personality disorder because it can feel like a mental health death sentence with little hope. Maintaining hope is incredibly important if someone is to succeed in therapy.


Many therapists choose to deal with the symptoms, and not fuss about the label. My Therapist rarely even mentions my diagnosis in favor of working on the very deep seeded issues I deal with. A therapist may note the possibility, they may come to a definite conclusion, they may even treat it for what it is, but unless a patient is assessed to be in a place that is receptive to understanding their diagnosis, it is not beneficial to the person to be labeled.

It can also take a clinician a longer amount of time to come up with a diagnosis of BPD because they only have a limited amount of time to share with their client per week. It takes time to get a full and accurate picture. This depends on how often they see a patient, the communication skills of the patient, whether they’re currently in crisis (which can make communication more difficult), the persons level of self-awareness, their honesty, and how long it takes to develop a trusting relationship with the therapist. Something people often take for granted is that the patient/clinician bond will form quickly and effectively. For many of us with BPD this is not at all the case. We have a very difficult time trusting, we may have constancy issues where we are unable to form an emotional bond with someone we see so infrequently, the more we share the more afraid we can become that the person will reject us… the therapeutic relationship is very complicated for someone with BPD and it cannot be rushed or taken for granted.  It takes time to learn a patient’s limits and tolerances. As we know, it doesn’t often pay to be brash or insensitive to someone with BPD.

Many people have preconceived notions of how therapy should go and expect results to manifest within a certain timeframe. I’ve heard over and over that people believe a therapist is to nice, too coddling. Significant others of those being treated for BPD will often become frustrated that a therapist is taking their time without pushing too hard.  “ I mean, come on, after meeting every week for over a year you gotta push the client at some point!”  Just because you think therapy should be going a certain way, doesn’t mean you’re right in what a person needs. That frustration is valid, but in therapy there is a lot more going on than confronting an issue and telling a person they’re wrong to experience that way. Especially as the reality may be that you don’t fully understand the depth of the issues this person is dealing with and are looking at it from a perspective that these changes should be easy to make once acknowledged.

The therapeutic process for Borderline Personality Disorder can take years. Depending on the initial trauma(s) that exacerbated the disorder it can take even longer. Often BPD is preceded by a childhood/adolescence of abuse, abandonment, and mistrust. Things most people are not willing to discuss with anyone. Issues like these cannot be treated lightly and the resulting coping mechanisms (as maladaptive as they may be) are strongly ingrained as a means of survival. Often a patient needs an aspect of limited re-parenting and the ability to develop a trusting relationship with an adult in a safe place, without the pressure to be something they aren’t ready to be.  The goal is not merely to acknowledge bad behavior. The goal is to change these deeply ingrained maladaptive coping instincts, but in order to do that, you have to develop a relationship that allows for the trust necessary to cultivate new experiences. What people interpret as “not pushing” a patient, may be a different therapeutic process altogether; forming a significant therapeutic bond. One that that does push that patient, work on coping in more constructive ways, even though you may not think it is going fast enough for what you’d expect. There can’t be any deadlines for healing and therapy. Behaviors created to deal with a lifetime of repercussions from trauma aren’t going to be changed overnight. But if you allow the therapeutic process to unfold how it needs to, at a pace the clinician feels is healthy for their patient, then there is a much greater hope for lasting healing.

The point is, it’s up to the therapist/clinician/psychologist/psychiatrist to deduce if a patient is ready to hear a formal diagnosis, and it’s up to them to decide if it will be a productive part of therapy and when.
Many good therapists don't get into the borderline labeling or don't make it the focus. There is no secret therapy path that begins with telling the patient a diagnosis. 

Oh, I’m going to keep going. With BPD there are often many co-morbid Axis-I disorders as well (i.e. depression, anxiety, panic attacks, etc). These may or may not be related to the origins of the Axis-II BPD diagnosis, but they contribute regardless. When there are co-morbid symptoms therapy and treatment becomes more complicated because there are more things to consider.

And finally, why shouldn’t you tell someone they might have Borderline Personality Disorder? Because you could be wrong. Many people have Borderline-like traits. Many people may seem to qualify for more than 5 diagnostic criteria but don’t meet the kind of severity that quantifies it as disruption of lifestyle. It doesn’t mean they aren’t often difficult to deal with. It also doesn’t mean these people don’t have problems that would greatly benefit from therapy. However there are many other things, or combinations of things, which can present as BPD that aren’t and only a licensed clinician is trained to figure this out.

Hell, I remember one time Evil-Ex thought I might have Multiple Personality Disorder (DID now) because my sense of self was often so flexible. I’m sure it made sense to him, but that doesn’t mean he was right.

When I first started presenting with real disordered behavior that others could see (emotional outbursts, cutting/suicide attempts, etc.) I was forced to see a therapist. I was only 12/13 years old, didn’t believe there was anything really wrong with me, didn’t believe I needed help, didn’t want help, didn’t trust anyone enough to actually care or have my best interest in mind, I was sure the adults were just out to get me… telling me I had any diagnosis or even a real problem at the time was met with extreme rejection, and I refused help altogether. I felt attacked and more alone than ever. The approach my school and my parents used on me wasn’t productive to what I needed.

It wasn’t until I started college that I was ready to accept that something was wrong with me. That how I continually felt wasn’t right and that I would do anything to live better. That’s when I was ready to begin looking into what my problems might be. Ready to learn that there was a name for what I was experiencing. For me, when I was ready, learning that there was something to call all of this was a relief. Knowing that it had a name, meant there were others that dealt with this; that I wasn’t alone. It also gave me hope that since it was something real, there was also a real way to treat it. And ultimately live a better life.

And we can. Each person gets to that place in their own time. Often as a result of the detrimental experiences that our loved ones want us to seek therapy for.

“Diagnoses can make sense of what can seem like a mish-mash of painful, incomprehensible life experiences including our current feelings. Diagnoses can also point the way to treatments that might be helpful. And diagnoses can undo the thought "No one else has ever felt this way" and the resulting miserable isolation. When we are miserable, it can feel good to know that others have felt the same and found their way to the other side.

But the key word in your question is "...HAVE..." The way we think about ourselves (and others) can be constricting or expanding. The danger is that if we think we "have" these "disorders," we may also think they are concrete, physically-based, perhaps genetically-based factors dictating our future feelings and our life.

Diagnosis can validate our feelings, but it can also trap us.

While we can't change the genes we got from our parents, or the way they raised us, or much of how others behave, whatever one's experience (whether labeled with a diagnosis or not), we can change how we think, which can change how we feel now, how we act next, and thus can change the trajectory of our life. This is true even if we have a "disorder" with a genetic component.”

Think of it in terms of obesity. Say you have a very overweight friend. How much good would it do to tell them they’re fat, they have a weight problem, and that their poor eating habits are having negative effects on their health? Not much, because they already know that. Plus it’s also insensitive, going to make them feel attacked, and hurt. It would be more productive to state your concern for their health and encourage them to see a doctor to develop a healthy nutrition and exercise plan.

Gentle encouragement to get help in a way that is validating and supportive should be encouraged. Don’t make the mistake of giving someone an unofficial diagnosis though.  You could be doing more harm than good. 

4 comments:

  1. Most therapists I have encountered always say that diagnoses are really only clusters of symptoms grouped together for convenience, and virtually no one fits each cluster perfectly. Diagnoses, it seems, are for insurance companies, not patients or doctors, who prefer to attack symptoms one-by-one. I typically came into therapy demanding to be told "what I was", and having that request denied again and again. And that demand, in itself, turned out to be a symptom...

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  2. i can't see if someone is borderline i can see if someone is more sensetive and more empathic than normal to mee it looks if these 2 are 2 high and they mess with your system you can be borderline right?
    is this true for all pd's (and sociopaths) no one can tell?

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  3. The is extremely good advice. Thank you.

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  4. If anyone wants to weigh in...my husband of < 6 months seems very clearly to me to be struggling with BPD. We've been together for nine years and it's been rocky but it seemed like we were putting everything behind us in getting married.

    Flash forward four months and he is posting ads for casual sex, mistrusting everything I say and leaning on his therapist who, if he's got a clue that it's BPD, is certainly not saying anything to him. So, here's the question (and I'm genuinely seeking advice): it is quite likely that we will divorce after < 6 months of marriage not because we don't care about each other but because of undiagnosed BPD.

    The latest "run-up" went like this: he was in the shower and had the thought that I could just up and leave him flat (no grounds for this whatsoever.) That led him to scrutinize my behavior for "signs" that I might do so. Frankly, he needs better help than he's getting and he won't get it if I don't speak up. Should I really just stand by and let my marriage fall apart because his therapist is working through problems on his own time?

    Thanks for whatever advice you have.

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Leave me a comment! It makes me feel good and less paranoid about talking to myself =)

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