In Defense of the Mainstream Understanding of Borderline Personality Disorder

People are obsessed with causes. And those causes may embody sought after justifications.

In a recent article in Psyche about Borderline Personality Disorder (BPD), psychologist Alexander Kriss argued that mainstream psychology has misleading descriptions of the personality construct. According to the author, there’s a “common notion” that BPD is mainly a genetic disorder, but I’m unsure of what’s meant by common. In online circles, where people love to argue, there’s somewhat of a debate between the “trauma informed” camp and their opponents, whom are often presented as the biological determinists, or proponents of the medical model of mental illness. The above-noted comment is a refrain by those in that camp.

The author goes on to note that BPD was once viewed on a spectrum, with the borderline construct falling in between the neurotic and psychotic categories, arguing that it wasn’t as far away from normalcy, which was basically neuroticism, as it is now. This is a straw man. While personality disorders in the DSM are categorical clusters, no one argues, at least no one worth hearing, that a borderline character is a completely distinct form of abnormality. And few argue that borderline pathology doesn’t appear outside of the DSM diagnosis, as you can exhibit some traits and not meet the full criteria for it. So far, the author makes two false claims: A. BPD is presented as a genetic disorder by the proponents of the so-called “medical model.” B. BPD is completely distinct from a “normal personality.”

The author goes on to write that BPD is an extreme form of the human condition, which no one would deny, and then denies that it is by implying that those with BPD aren’t difficult and combative. You can’t, on the one hand, have turbulent emotions and, on the other, not be difficult and combative. As clinicians, however, we are trained to work with those behaviors and many find a lot of value in working with difficult patients. The term itself is a matter of fact, rather than an insult; so, instead of denying the reality of BPD, it might be more helpful to reframe the implications of being difficult (i.e. “It doesn’t imply that you’re a bad patient and will be rejected.”) and to try to understand the inner world of someone who presents a constant challenge, in turn helping them to take some responsibility for their interactions with others. In essence, and of significance, this is distinct from blame.

The dynamic is, sometimes, thus: You challenge my authority so I blame you for how poorly treatment goes. In this respect, the author was spot on; difficult patients are often blamed for treatment not working. But, blame and responsibility, the latter of which we hope to help cultivate, are different concepts. Responsibility asks: Can you try something else to help make this work better? Blame asserts: You should be punished for this not working. Patients often fear being blamed and discarded, shamed for their unwillingness to accept aid, which they tend to mistrust. Yet, blame, when it occurs, is always a defense for a sense of inadequacy. When therapists play the game of emotional hot potato, they merely deny their own scalding self-doubt. But, more seasoned clinicians search for ways of improving trust between them and their patients, asking: How can we make this better?

On X, psychotherapist Mark L. Ruffalo maintained, “Whether a diagnosis carries negative consequences, whether it is hated or loved by the patient or doctor, whether it carries social stigma or social benefit–all of these things are irrelevant to the central question, “Is disease present in this case?”” He’s completely right technically, in that an illness either is or isn’t there, but only partially right when considered broadly. In order for treatment to work, we also need to address the stigma and our obsession with causes. In defending against biological determinism (and the stigma attached), some people use trauma as a defense against shaming and a justification for most of BPD’s responses, implying, “This could be you.” Fundamentally, denying the significance of a genetic component is the same as denying the environmental one; we search for excuses – to give up on a patient’s treatment or to give up on ourselves.

People with BPD have histories of blame. And most clinicians know that. To argue that mainstream psychology doesn’t take that into account is either based on ignorance or bad faith. As the article draws to a close, the author notes that different patients benefit from different types of treatments, again, which no one would argue against. In railing against DBT, a behavioral therapy, the author creates the same straw man argument wielded by psychoanalysts: It’s cold, simplistic, and mostly directive. Yet, CBT, and DBT by extension, is none of those things. In reality, pure CBT therapists don’t exist; most are integrative, just like the author. So, whenever you find yourself caught up in some debate about concepts in psychology, ask yourself: Who stands to benefit? While I appreciated the author’s defense of his patients, I found myself asking: Is he defending them from the right people? And, how does he intend on helping them begin to move beyond the justifications to change? While the stigma associated with BPD should continue to be challenged, it isn’t prominent in mainstream psychology. People with BPD aren’t uniquely difficult in most therapists’ minds. When patients say, “I’m like this because of that,” few will blame them for it, but the good ones will ask: But can things be different?

Check out our episode with Mark below: