The stigma associated with borderline personality disorder (BPD) is well documented among the general public and within the treatment community. In this week’s episode, we discuss specifically why this disorder, and the people who are diagnosed with it, are so often stigmatized? Our guest expert, Dr. Seymour explains why this stigma is undeserved, especially today when effective treatment is available.

Dr. Seymour also discusses why it may be time to retire the label of “borderline” once and for all and rejects the notion that there is anything wrong with these patients, instead discussing the trauma of their life that, as a consequence, has led to maladaptive coping behaviors.

Gabe Howard
Gabe Howard

Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, Mental Illness is an Asshole and other Observations, available from Amazon; signed copies are also available directly from the author.

To learn more about Gabe, please visit his website, gabehoward.com.

Announcer: You’re listening tothe Psych Central Podcast, where guest experts in the field of psychology and mental health share thought-provoking information using plain, everyday language. Here’s your host, Gabe Howard.

Gabe Howard: Hey, everyone, you’re listening to this week’s episode of The Psych Central Podcast, sponsored by Better Help. Affordable, private online counseling, learn how to save 10 percent and get one week free at BetterHelp.com/PsychCentral. I’m your host Gabe Howard, and calling into the show today, we have psychiatrist Dr. James Seymour, who joined Sierra Tucson in 2010. Dr. Seymour received his medical degree from the University of Tennessee and completed his psychiatric residency at the University of Virginia. Dr. Seymour, welcome to the show.

Dr. James Seymour: Yes, thank you for having me, I appreciate it.

Gabe Howard: Dr. Seymour, in a previous episode, we learned all about the inner workings of borderline personality disorder, how it is diagnosed, symptoms to watch for and why it is so difficult to treat. Now, I was surprised by our listener email asking me why I ignored the controversy. People let me know that borderline is, in their words, the most stigmatized mental illness there is. Do you think that is true?

Dr. James Seymour: I would agree with that, except also those people with chronic psychotic disorders like schizophrenia, they’re often very discriminated against, but for a non-psychotic disorder, I think that people with borderline personality disorder diagnoses by far are the most discriminated against.

Gabe Howard: Why do you think that is? I know that people with mental illness in general, as somebody who lives with bipolar disorder, believe me, I’ve seen the stigma and the discrimination firsthand. But I was surprised that so many people with borderline personality felt that there was just an extra umph. Why is that?

Dr. James Seymour: Well, first, you have to understand what a personality disorder, according to our current diagnostic classification is all about. What we have is what I call categorical personality disorders. That is, we’re looking at pervasive patterns of behavior that continues throughout adult life with some precursors in childhood or adolescence. The problem with those is that they are basically categories and our personalities are much, much more complicated than any personality that we would give a name to. So I am not in favor of the current way of diagnosing personality disorders or chronic patterns of behavior that are maladaptive. Now, the borderline personality disorder is particularly difficult because the people who are diagnosed with that have unstable relationships, the relationships with the treatment providers are often unstable as well. Although there are adequate treatments for that now, they have been previously seen as untreatable. They have been discriminated against because often their behavior, self-harm behavior, suicide attempts repeatedly, other impulsive, self-destructive behavior create a lot of problems for the therapy providers. And so, they just develop negative feelings towards people with that disorder and so does the general population.

Gabe Howard: One of the things that I learned is that people with borderline personality disorder, they tend to seek out drama. That’s my layman’s term way of putting it. But I can see why somebody who doesn’t understand mental health issues and mental illness might see somebody who is involved in a lot of dramatic relationships or constantly fighting or arguing, why people might move away from people like that for their own mental health. But when one of the symptoms of borderline personality disorder is seeking out these unstable, dramatic relationships and people tend to move away from you, how do you bridge that gap? Again, I know that I would not be doing as well as I’m doing without the love and support of my friends and family, but if my friends and family had moved away from me that would have made my illness harder to treat. Now, as a psychiatrist, how do you get everybody on the same page when, well, when that’s the symptom?

Dr. James Seymour: The first thing I do is to reframe what is actually going on. Rather than use the term borderline personality disorder, I talk about what it really is about. It’s about a human being who has very maladaptive coping mechanisms to deal with a highly dysregulated nervous system, which is often secondary to trauma and/or genetic factors. So the emphasis on there’s nothing wrong with the person, the adaptive capacities and the adaptive means have not served them well in adulthood and are creating a problem with them and in their relationships. And once you do that, you take all the stigma away. We don’t permit any staff members here to refer to people as having borderline personality disorder. Basically, it’s a normal human being who has maladaptive coping mechanisms. Once you do that, the stigma is gone in my mind. Now, the biggest problem is we have the problem of having tribal brains. We developed for thousands and thousands and thousands of years in small tribes with 150 to 400 people competing for resources. Our brains have not changed, although society has changed. So when we’re in a tribal, ancient civilization, everybody else outside our tribe we’ll consider not people. And so we can do whatever we wanted to and we were justified in disrespecting them, making them enslaved, killing them, wiping them out, whatever.

Dr. James Seymour: Now, we still have that same way of dealing with what we would call an other. So any time we make an other, we will disrespect them and we will mistreat them even though we don’t want to. And I’ll give a couple examples of that. Let’s look. I am white. You are a person of color. I am male. You are female. I am straight. You are gay. I am German. You are Jew. I am staff. You are patient. I am normal. You’re borderline. Any time we do that, we will disrespect and create problems for that other person. That’s one of the things you really have to use to fight the stigma and help the patients understand that although they have very significant symptoms and although they have very difficult interpersonal relationships, at the core, there’s really nothing wrong with them because they feel that there’s something terribly wrong with them, that they are flawed in major ways or they’re bad or they’re untreatable. And so the focus is on, no, there is nothing really wrong with you except behaviors, which has become maladaptive. And we all we need to do is help you to change those behaviors.

Gabe Howard: Obviously, we know that there’s a lot of stigma surrounding mental illnesses, and as we’re talking about, there’s even more for borderline personality disorder, do you think one of the reasons that there’s more stigma is because there’s no medication option for patients with this diagnosis? So that makes people think that maybe it’s, I hate to use the word fake, but because there’s no definitive testing for mental illness, everybody looks at it sideways. But I think that if you’re taking medication for something, people are like a doctor prescribed medication. So it must be maybe real. They start to turn the corner a little bit. But then when we get to borderline personality disorder, it’s only therapy. If it’s only therapy, then maybe it’s a, and it’s even got personality disorder right in the title.

Dr. James Seymour: Yes,

Gabe Howard: Does this contribute?

Dr. James Seymour: I think it contributes some in terms of the medication. I think the great deal of stigma is because these patients are some of the hardest to deal with. If they’re hard to deal with therapists and doctors, they’re very difficult to deal with their families and loved ones because of the instability of the relationships, the tendency towards anger, the difficulty with emotional regulation. So they’re seen as a behavioral problem rather than somebody that has treatable emotional difficulties. And actually, it’s not a disorder or illness, per se, because the personality disorder diagnoses are not felt to be illnesses, but pervasive patterns of being in the world and relating to other people and themselves. So it’s not really a mental illness. It is, again, maladaptive coping mechanism to deal with a dysregulated nervous system. And just once you get to that point, then you get rid of all the stigma. Now, medications are used very frequently, but they’re used to treat some of the major symptoms. So somebody may be on a mood stabilizer for regulation of the mood. Somebody may be on an antidepressant for recurrent depression and suicidal ideation and suicide attempts. So we do use medication, but not for the diagnosis. We use medications for the symptoms that are troublesome for the individual to manage even when they’re in therapy.

Gabe Howard: One of the things that you’ve made reference to is that the providers find them difficult to work with, are

Dr. James Seymour: Yes.

Gabe Howard: The providers accidentally creating more stigma by making that known?

Dr. James Seymour: I am sure that is the case, I’m sure it spreads from the hospitals, treatment centers, psychiatric offices to the general population, I’m sure that it has something to do with it.

Gabe Howard: And do you think that that name contributes to some of the stigma and discrimination against patients who have this diagnosis?

Dr. James Seymour: I think we should stop using the term altogether. I think by using the term it’s been in use for so long, we’re never going to change people’s view, never going to change therapists’ and doctors’ view of what we’re dealing with. We’re always going to make them an other and we will always mistreat them. And when working with these patients who had been diagnosed with that, they pick up subtle signs of disrespect very easily because they’ve been generally severely traumatized and experienced a great deal of abuse in their lives. And so by just not thinking of that disorder, what happened is when we work together, some of those negative maladaptive behaviors go away because we’re just treating each other as one person to one person. So I don’t think anything’s going to happen until we get rid of that diagnosis. It’s a label.

Gabe Howard: And what would you call the diagnosis instead? We’ve got to call it something.

Dr. James Seymour: The thing you really look at it is it’s a disorder of two aspects, it’s trauma related in many cases and also attachment related. If people used words like trauma related problems or trauma related developmental problems or trauma and attachment developmental issues, something like that takes a lot of stigma away.

Gabe Howard: We’ll be back in a minute after these messages.

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Gabe Howard: And we’re back with psychiatrist Dr. James Seymour discussing the stigma of borderline personality disorder. I’m still sort of hung up on the words personality disorder because most people understand personality to be just your personality. We all have personalities and some people’s personalities we’re drawn to, some people’s personalities we dislike, some personalities we like, etc. So the minute you say personality disorder, I think that most people think that what you’re saying is that person has a bad personality.

Dr. James Seymour: Yeah.

Gabe Howard: Is there a way to move away from that?

Dr. James Seymour: Yes, and that is to not use a personality disorder diagnosis at all. That’s the only way you’re going to be able to do it, because personality, as you say, is much, much more complicated than just a category. And by using what I call these categorical diagnoses, we are putting people in boxes and people don’t live in boxes. They live in real life with real life issues and real-life problems. Until we get rid of that whole section that there is such a thing as a personality disorder, they’ll continue to be stigma.

Gabe Howard: Dr. Seymour, from my perspective, another thing that leads to stigma is that it seems to be people with a borderline personality diagnosis don’t get treatment until something like extremely serious happens. They hurt themselves with self-harm or they get in an accident taking unnecessary risks. They don’t seem to get the help that they need when they’re, and I’m making air quotes here, just being dramatic. Is there a way to educate the public, even people who may have borderline personality disorder? Is there a way to educate the public to get these folks help before something really serious happens? Or are we stuck only reacting to the crisis?

Dr. James Seymour: I think if we were to educate the general population that problems with impulse control, behavioral difficulties, unstable sense of self, anger problems that there might be something that’s treatable with them, that there’s something that could be helped by mental health therapy of one kind or the other, and that the families would encourage people to get treatment earlier. That’s one of the things I think we can do is to say when having these behavior problems, let’s think about it. It might not be just behavior. It might be something that we can do something about.

Gabe Howard: So let’s picture a world where Dr. James Seymour runs it. You are now in charge and you’ve decided that you want to help remove all stigma for mental illness, not just borderline personality disorder. Do you have any thoughts on how you would go about that?

Dr. James Seymour: That’s a good question. I’m glad I’m not in charge of the world, but I don’t think we’ll ever eliminate stigma. We can reduce it. Because any time someone behaves outside the norm, there will be stigma. There’s no question about it. That’s just what’s going to happen. But I think we can reduce it a lot. One way to reduce is to reframe and use a paradigm shift in terms of how to view psychiatric disorders. For over 100 years, 120 years now, we’ve used what’s called the psychopathology model. That is we’re looking at, OK, what is wrong with the person? How do we make a diagnosis? How do we research these people? How do we treat them? So we put them in categories of similar type behaviors. Now, that model has served its time. It’s time for it to be done. Instead, what we need to move to is what I call a neuro regulation model that is more consistent with what we know about brain development, early life attachments, the growth and development of children to adults, and actually how the brain operates. So I call it a neuro regulation model. And so in that type of model, you were looking at how someone regulates the nervous system both in adaptive and maladaptive mechanisms. And you’re not looking at a diagnosis. You’re not looking at a label.

Gabe Howard: One of the things that persists is that borderline personality disorder cannot be treated. Now, I believe that if something can’t be treated, this is going to create a lot of stigma, because if you think that there’s no treatment, that means you believe that person will behave this way forever. Therefore, cutting ties with them or discriminating against them doesn’t make you feel so bad. Now, my biggest question is, is borderline personality disorder treatable?

Dr. James Seymour: It’s very treatable. One of the main psychological treatments is what we call dialectical behavioral therapy, which was brought about by a genius psychologist in Washington, Marsha Linehan, and she developed the idea of dialectical behavioral therapy. Now, dialectic being the Greek word for a merging of opposites and the main opposites that merge are the opposites of acceptance versus change for these people. If we expect them to change right away and they cannot, that increases their shame and increases the likelihood that the behavior will continue. If we accept them just for who they are and get them to accept themselves just for who they are at the moment, and then we can move towards change. That’s more effective. And I’ll give an example of that. AA has known this for a long time. Alcoholics Anonymous, when you go to an AA meeting, you’re brought into the fold right away, you don’t have to stop drinking. You don’t have to stop changing. All you have to do to be a member is the desire to stop drinking. So you’re accepted first and only after you’re accepted and part of the group do they expect you to change by following the 12 steps. A lot of religions are the same way. You’re accepted by God, or the source, or light, or whatever you want to call it.

Dr. James Seymour: And then there’s a path to recovery. You’re accepted first and accept for who you are. And whoever the God is that you worship accepts you for who you are and then you’re able to change. So I think that’s one of the main things. The other thing that dialectical behavioral therapy teaches is four major things, and one is distress tolerance. That is what can I do other than harming myself or acting in an impulsive way? How can I handle my distress in other ways? The second thing they do is mindfulness, and mindfulness is the ability to step back and notice yourself. So rather than just being in the problems, they’re able to step back and look at their problem and therefore able to make some changes. The third aspect is emotional regulation, and the fourth aspect of it is interpersonal relationships, learning better, I call it just learning better communication skills. And those four areas, you can teach those skills very easily and very effectively and they can be very helpful. Also, medications are very helpful when you can treat certain symptoms such as mood instability, severe depression with suicide and suicide attempts, medications, non-addictive medications for high levels of anxiety. So there’s both psychotherapy that treats the problem and there’s also medications that support the psychotherapy.

Gabe Howard: And psychotherapy is very effective toward getting the life that you want.

Dr. James Seymour: The dialectical behavioral therapy is very, very effective.

Gabe Howard: Now, dialectical behavioral therapy, or DBT, that’s something that gets talked about a lot, but I don’t think that many people understand it. And if I’m not mistaken, there’s even some controversy and stigma surrounding that, even though it’s empirically proven to work.

Dr. James Seymour: People don’t understand it because it sounds strange, too. Dialectical behavioral therapy. What is that? What does that consist of? But if you look at it consist of teaching four major skills, people can understand that. The skills in terms of distress tolerance and the skills in terms of mindfulness skills, in terms of emotional regulation, the skills of interpersonal relationships and communication skills, that’s really all that it is. And so the dialectical behavioral therapy way of approaching things is useful not only for people who are diagnosed with borderline personality disorder but across all diagnostic categories. And everybody can benefit by those dialectical behavioral therapy skills.

Gabe Howard: And just to really clarify for the audience, the term dialectical means concerned with or acting through opposing forces or relating to the logical discussion and ideas of opinions, and that, that’s sort of where we get DBT right? Because it’s

Dr. James Seymour: Yes.

Gabe Howard: It’s looking at the world differently, reframing and changing your behavior. And of course, we all know what therapy means.

Dr. James Seymour: Yes, yes, I agree with you. Yes, I think you said it better than I did.

Gabe Howard: Thank you so much. From your perspective, this is working, you have seen people with borderline personality disorder come to you, get treatment, and lead better lives. We’ve talked a lot about the stigma. We’ve talked a lot about discrimination. Let’s talk about some successes. Do you have any great success stories of people who have come to you or Sierra Tucson for help and are now living perfectly normal lives because they got treatment?

Dr. James Seymour: Yeah, that happens all the time and a couple of things. Remember that many of these people have a significant amount of early life trauma. Trauma focused treatment can be also very effective in addition to dialectical behavioral therapy. I’ve had people that were diagnosed as borderline personality disorder, and the problem is that nobody ever put them on a mood stabilizer. The mood stabilizer helps. So it may be was there an underlying bipolar disorder that it was unrecognized? Or was it just the medication helped stabilize the mood? I’ve seen people like that. I’ve seen many people who had been from one therapist to the next and have recurrent self-harm behavior and suicide attempts who once they are able to deal with the underlying trauma issues, are able to do much better. I’m confident and optimistic for everyone. And I say no matter how early your trauma was, no matter how late it was, no matter how young you were, or how old you are now, everyone can recover to some significant degree.

Gabe Howard: There are so many people living with borderline personality disorder that you would never know because they’re just living their lives. I’ve often said that crisis in any mental illness is very public, whereas recovery in mental illness is very private, giving folks this idea that people with mental illness are never recovering because we’re only seeing the crises. And I think borderline is definitely impacted by this because it has so many symptoms that just could be drama or temper tantrums or immaturity. And I think they just get thrown all in the same basket. Is that your general thoughts?

Dr. James Seymour: I agree with you, I think that’s a good way of putting it. I think that’s where a lot of stigma comes from and by education and getting people into treatment modalities sooner, we can help more people.

Gabe Howard: Dr. Seymour, I know that you know a lot about this disorder, about this illness. Do you have any final parting thoughts for our audience?

Dr. James Seymour: Yes, instead of using the borderline personality disorder diagnosis, just remember, these are maladaptive coping mechanisms to deal with a highly dysregulated nervous system, often secondary to trauma and or genetic factors. If people get that, I’m very happy.

Gabe Howard: Thank you so much for being here. We really appreciate having you.

Dr. James Seymour: Thank you, I appreciate you having me too.

Gabe Howard: All right, listeners, I need a very big favor. Wherever you downloaded this podcast, please subscribe. Also, use your words and tell people why they should listen and why they should subscribe. Give us as many stars as you feel that they have earned. My name is Gabe Howard and I am the author of Mental Illness Is an Asshole, which is available on Amazon.com. Or you can get signed copies for less money by going to gabehoward.com. We’ll see everyone next week.

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