Gender, Stigma, and Bias: Everything We Get Wrong About Borderline Personality Disorder

For many years, I ran a weekly therapy group aimed at clients who had trouble regulating their emotions and interacting with others. The group utilized an approach called Dialectical Behavior Theory (DBT). As I would explain to the group members, things like learning how to anticipate and respond to your emotions or how to best ask for what you need from others aren’t hardwired in us but are taught to us by our parents and other influential figures. If this doesn’t happen, you may not know how to navigate such situations through no fault of your own. Although the clients who filtered in and out of the group came from a variety of different backgrounds, many had a shared diagnosis: borderline personality disorder (BPD), the condition that DBT was created to treat.

During one session, a newly diagnosed member brought in a bright yellow book called F*ck Feelings, a self-help book written by the Harvard-educated psychiatrist Michael I. Bennett and his daughter, comedian Sarah Bennett. “Do you know what this says about us?” she asked the group, indignant. I didn’t, but I had an inkling. I began to cringe before she started reading.

She found the definition of borderline personality disorder and began: “These are the people, usually women, who lonely, crazy-prone single guys often find irresistible… Their dates (and friends and family) are always walking on eggshells, which makes sense when you’re dealing with someone who treats each thought and feeling as empirical truth; i.e., ‘I am attracted to that guy’ quickly becomes ‘that guy is the best thing to ever happen to me and I must get his baby in me ASAP.’ She is incapable of doubting her instincts, but she makes up for it by constantly doubting the motives of everyone around her.”

The room fell silent as the weight of the words sank in. A painful discussion about how others perceive their mental illness ensued, and while the members of the group drew meaningful connections between similar experiences, the sting of the book lingered. I tried to explain how and why the book was wrong, both in its content and its approach, while also making space for the fact that many medical professionals did in fact think such things. The group members didn’t need to be told this, of course; echoes of past interactions with doctors and therapists were quickly brought to mind by the words of the book. It pained me to realize some of those involved my coworkers.

It’s common in the mental health field to use person-first language such as “a person with schizophrenia” instead of “schizophrenic.” We do this to remind our patients and ourselves that no matter the diagnosis we are all human beings worthy of dignity and respect. This is so commonly observed so as to pass unnoticed, yet team meetings at that job often included mention of difficult “borderlines,” usually in reference to those gathered in that very room.

I wrote at length in This City Is Killing Me about the lingering stigma associated with the diagnosis of borderline personality disorder through the lens of my client Jacqueline, who was not a member of that group but had many of the same experiences. It is safe to say that borderline personality disorder is one of the few diagnoses that even seasoned mental health professionals will wince at and hesitate to take on as a client. Nearly every client whom I see in my private practice with such a diagnosis reveals it to me in hushed tones during our initial phone consultation, bracing for the inevitable rejection.

To be borderline is to occupy a liminal space, unsure of the path forward. Pop songs talk about relationships on the borderline, tilting erratically between the promise of ecstasy and the fear of falling apart. In an age of increasing nationalism, the borderline is a place to be fortified, guarded, to protect the supposed sanctity of the nation-state. Both describe a sort of contested space, neither here nor there. All of us may be able to imagine this sort of state in our relational patterns or countries of residence, but what does it mean to apply such concepts to our minds?

Borderline is a concept dating to the days when psychoanalysis dominated the psychiatric mainstream. For most of his career Freud was interested in treating neurotics (this before the advent of person-first language, of course), the sort of everyday anxious and depressed people that continue to make up the majority of mental health patients. The other side of the spectrum included the psychotics, those whose perception and way of being in the world was fundamentally different from what the majority experienced. Freud thought psychotics were incapable of being psychoanalyzed, and while other practitioners dating to the first few decades of psychoanalytic thought believed otherwise, all agreed that their treatment looked quite different. Some patients seemed to be in the unstable middle, not entirely psychotic but also with problems beyond pure neurosis. These patients existed in the borderlines between the two categories, hence the name.

Neurotics and psychotics each present with their own difficulties, but they at least can be named, and there is some predictability to the ways they act and how their symptoms manifest. The borderline lacks such stability, a sense of a continuity of character from one moment to the next. In the borderline, one can never know what they are getting into, both for the patient and the mental health professional. The ways in which persons with BPD are talked about in the literature often reinforce this “borderline” status.

While our diagnostic nomenclature has moved beyond the neurotic-psychotic binary, borderline personality disorder continues to share some core features from its days on the psychoanalytic continuum: the need to attach to others as transitional objects, a distorted sense of self and others, fears of abandonment. Along the way toward scientific respectability, it became attached to a series of diagnoses: at first it was placed on the schizophrenia spectrum, later it became linked to depression. It has long been “an adjective in search of a noun,” in the words of one famous paper. For the past 40 years, it has been a part of a cluster of diagnoses known as personality disorders.

Prior to DSM-5, these disorders were kept separate from the other diagnoses grouped along Axis I and placed in their own category, Axis II. While this is no longer the case, personality disorders remain profoundly different from most other mental disorders. Personality disorders shape the way one experiences and interacts with the world; they become attached to one’s self in a way we don’t normally think of when we talk about depression or schizophrenia. With those disorders, there is a clear before, a sense of self that extends beyond the experience of the illness, and with time and treatment this sense of personhood is hopefully restored (at least to some degree). Clients with personality disorders, though, usually report that they have always been this way. Their symptoms might increase or change somewhat over time, but they usually can’t remember a time when their life wasn’t impacted by their diagnosis even before they first heard the name.

None of this means that people with the symptoms of borderline personality disorder are incapable of being treated. Contrary to the assumptions of many, including mental health professionals, the disorder responds well to treatment, often with Dialectical Behavior Therapy or another approach designed to help patients better understand the emotional lives of others. People with the disorder often suffer terribly, so this is undeniably good news. The stigma attached to the diagnosis, though, has yet to catch up.

The ways in which persons with BPD are talked about in the literature often reinforce this “borderline” status.

The most common adjectives used to describe people with borderline personality disorder include manipulative, needy, seductive, and fearful of being rejected and willing to do almost anything to avoid it. Women with characteristics of borderline personality disorder dominated the erotic thrillers that thrived at the box office in the late 1980s and early 1990s. Consider Glenn Close’s character Alex Forrest in Fatal Attraction. After having a fling with Michael Douglas’s character, Dan Gallagher, who is married and has a family, she claims that she is pregnant, attempts suicide in front of him, begins stalking him, and kills the family rabbit before attempting to kill his wife.

Other fictional portraits are more nuanced, like the main character in the television show Crazy Ex-Girlfriend, but with perhaps that exception people with borderline personality disorder are rarely allowed to be fully human, instead relegated to a barely-animated catalog of threatening symptoms that often have to be met with violence to spare their victims from further machinations.

As Susan Sontag argued in her Illness as Metaphor, both physical and mental distress are placed within narratives that shape how they are experienced and how we talk about those experiences. Not all diagnoses are seen to subsume one’s subjectivity in the manner of a personality disorder. You experience depression; you have schizophrenia; you are borderline. We speak of those who experience most mental illnesses as struggling or suffering from them, but when it comes to the language we use for borderline personality disorder we mostly focus upon its impact upon us: we are the ones allegedly being manipulated, seduced, clung to. No other mental disorder is so focused upon the impact the person with the diagnosis has upon others.

Our focus upon the impact people with borderline personality disorder has upon us elides an important fact: we all manipulate and cling to others. By writing these words on a page, I am hoping to offer something compelling to my readers to gain their attention. I have those in my life whom I cannot imagine living without. The implicit critique in assigning these qualities to people with borderline personality disorder is that they aren’t that good at them. I recall a client from my former DBT group who often got into disputes with other group members, usually due to her becoming too reliant upon them outside of our sessions.

In pain and desperation she would reach out, they would inevitably fail her in some way, and she responded with fury papering over a deeper sense of hurt. Every time this happened, and it happened often, she would try to steer the subject discussed that week back toward a barely-veiled critique of the person whom she believed had wronged her. This was all quite transparent; she and many others with BPD had not learned the subtler ways in which we try to influence others.

I cannot deny that she and other people with borderline personality disorder suffer—I have seen it too often to believe otherwise—yet the ways in which we conceive of the diagnosis shape our experience of it beyond what the concept of stigma can capture. There is something else vitally important to consider when it comes to the concept of borderline personality disorder: gender. As late as the DSM-IV-TR (2000), it was thought that three times as many women merit the diagnosis as do men. While it is now assumed that men and women experience the disorder in equal proportion, the majority of patients seeking treatment for the disorder continue to be women.

Men with the diagnosis present differently, tending to have an explosive temperament, engage in frequent risk-taking, and have substance use problems. These are serious issues, to be sure, but for most people, even mental health professionals, this doesn’t sound like what we are trained to recognize as borderline personality disorder. Many of these men most likely end up with a diagnosis of bipolar disorder, itself a subject of stigma but not nearly to the same degree. The prototypical borderline patient is almost always coded as feminine.

Consider again the symptoms of borderline personality disorder. An unstable sense of self, fears of abandonment, difficulties maintaining relationships, self-harm behaviors, mood instability, feeling empty, dissociation, outbursts of anger, impulsivity: if you remove the concept of mental disorder, does this not sound like every patriarchal stereotype of women that you have ever heard? If they are women we don’t like, they are crazy, manipulative “bitches”; if these traits are portrayed in a positive light, they are manic pixie dream girls, a term first coined by the film critic Nathan Rabin.

Borderline personality disorder is the most egregious example of a gendered personality disorder, but most of them demonstrate some degree of gender bias. As our understanding of the construction of gender has increased, it has become further evident that traits stereotypically associated with femininity are far more likely to be categorized as a disorder. One study found that male-identified people with a high degree of non-masculine behavior were more likely to have features of all personality disorders save antisocial when ranked by both themselves and their peers. The same did not hold true for women-identified people with a high degree of non-feminine behavior, who were seen as having less features of a personality disorder by their peers. The implication is clear: no matter one’s gender identity, the higher one evinces traits stereotypically associated with femininity, the greater one’s chances of ending up with a personality disorder.

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Excerpted from (Mis)Diagnosed: How Bias Distorts Our Perception of Mental Health. Used with the permission of the publisher, Belt Publishing. Copyright © 2021 by Jonathan Foiles.