In 1980 the mental health industry invented a new diagnostic label, one of many, for the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III). The American Psychiatric Association (APA) presented DSM III to the world as a scientific revolution in psychiatric understanding. If people suffering emotional distress had accepted the APA’s statements about the new manual, they would have rejoiced that such a wealthy and powerful organisation had put its energies into making sense of psychological suffering. The vast majority of people receiving one of these new labels had experienced great trauma – sexual abuse, extreme life events and repeated abuses of power. Quite a progressive move by the APA then: understanding the effects of power on people. Psychiatrists could show care, understanding, and perhaps even provide a sense of solidarity to people who were marginalised. Unfortunately, in 1980 the APA willed Borderline Personality Disorder into being. The APA’s idea of empathy and understanding led to vast numbers of survivors of abuse being labelled as disordered individuals.

In many ways the diagnosis of BPD is an easy target for criticism and satire. The diagnosis of BPD is defined by a series of social and moral judgements, applied to people who have been traumatised and dressed up as a medical problem. If we had a friend who revealed to us after years of secrecy and shame that they had been repeatedly sexually abused as a child, our first response is unlikely to be “your personality must be really disordered – no wonder I’ve felt like rejecting you”. Instead we would show care, be amazed at their survival and probably feel anger at the perpetrators of abuse – basic common sense and decency. Sadly when it comes to psychiatric diagnosis good sense does not prevail. The survival of psychiatric diagnoses is in many ways an astonishing feat of magic; its supporters have woven a spell that repels good sense, compassion, logic and evidence.

There are multiple problems with a diagnosis such as BPD. Here I want to highlight just one: it locates the problem within the individual. ‘BPD’ hides disordered environments, misuse of power and perpetrators of abuse. The following quote from Suzi, someone who received the label, makes the point better than I can:

‘I cannot understand how the vast majority of perpetrators of sexual violence walk free in society; whilst people who struggle to survive its after effects are told they have disordered personalities’ (Shaw & Proctor, 2004, p.12).

Think about the implications of that for a second. It’s accusing us of failing to recognise the abuse of power in society, of colluding in suffering. People are traumatised and hurt in many ways. For some there are obvious damaging events involved, for other people the circumstances are more complex and subtle. The flow of power is usually crucial in each. Unfortunately, the way in which we offer mental health services can lead us to ignore life circumstances and power. An understandable reaction to a horrifying life experience is converted into an illness, which a person is held responsible and rejected for having.

If that doesn’t paint a pretty picture of mental health services what are the alternatives? Perhaps a little good sense might help here. We need to support people to make sense of their distress in relation to their life experiences and circumstances – survival strategies in the face of disordered environments. People need to be offered practical support and guidance, as well as compassion and care. It seems unnecessary to grab at the concepts of illness, treatment and disorder, when we can talk with people using ordinary language. Our conversations need to honour people’s survival and strengths against the odds, as well as their difficulties and needs. When supporting people who have experienced high levels of abuse and are struggling in life, workers need space, supervision and time to reflect on and cope with their own feelings, and to consider the most useful ways to help. People should not have to accept a label and the attached baggage to receive support.

Abuse and misuse of power are social and political issues. We seem to resist asking the questions that flow from this though. Such as why is sexual violence so prevalent in society? How do we prevent people doing horrendous things to each other in the first place? What economic policies decrease oppression and misuse of power in society? Going back to the 20th century, at one point the APA decided people who identified themselves as gay were suffering from an illness. Some of those who were labelled accepted and internalised the label. However due to lobbying and activism this idea was eventually abandoned. It is now time to speak up and say that people in emotional pain, who have suffered and attempted to survive, should no longer be labelled disordered. It is time to abandon the concept of borderline personality disorder and instead find and honour the person.

Shaw, C. & Proctor, G. (2004). Suzi’s Story. Asylum (Special Edition: Women at the Margins), 14 (3), 11 – 13. Also reproduced here.

About the author

Steven Coles is a Clinical Psychologist  and co-editor of Madness Contested: Power and Practice (PCCS Books, 2013). Follow him on Twitter.