Vulnerability is the royal road to encounter our authenticity. Vulnerability can allow expressions of thought and feeling that a familiar role has made difficult to share. There are individuals in our midst who are committed to this sacred path of living authentically and have much to teach us, but instead of learning from them, we have often diagnosed them. Paradoxically, these individuals can feel lost and be hiding in identities that are not fully themselves, struggling with self-harming behaviors like addictions and eating disorders.
They may pass through inpatient and outpatient mental health services and encounter providers who experience their distress as manipulation, without sufficiently considering the relationship or the treatment setting. A person can become caught in an image of being ill, difficult, or dependent, while a treatment system inadvertently reinforces the role it hopes to change. This is a concern about how care is organized, rather than a conclusion about why a person relapses. So maybe our collective imagination needs to change so that the clinician's vulnerability shifts first and then their patient may follow.
Abandonment lies at the core of many individuals with BPD, as they often experience intense fear of being rejected or left alone. For some people, early experiences of separation or inconsistent care are important; a diagnosis does not establish a particular childhood history. These individuals may struggle to form stable and secure relationships, constantly seeking reassurance and validation. Unfortunately, the misuse of the BPD diagnosis often leads to further abandonment, as they are labeled as difficult or attention-seeking rather than understood and supported. This perpetuates a cycle of invalidation, reinforcing their fear of abandonment and making it more challenging to develop authentic connections. (National Institute of Mental Health)
The concept of projection is the idea that we project what we don’t like about ourselves onto the vulnerable other who has little power to defend themselves properly. Instead of using defenses like humor, deflection, and disavowal, the person may identify with who they are suggested to be to avoid shame and guilt and their personality transforms into the person they are not authentically. Projective identification is another theme that emerges in the context of BPD diagnosis.
As noted, projection is a defense mechanism that involves unconsciously projecting one's undesirable thoughts, feelings, or attributes onto others, often followed by a profound urge to control and manipulate them. While this behavior can be observed in individuals with BPD, it is important not to treat projective identification as a behavior unique to BPD or infer it from a diagnosis. Caregivers, and therapists, can also project onto the patient this idea of borderline and the patient or client identify with this message and begin acting out the behavior in the room with the clinician and thus enacting a vicious cycle of inauthenticity and further abandonment of the patient. (Klein, 1946)
Abusive provocation by caregivers is a third theme that contributes to the misuse of the BPD diagnosis. The individuals I have worked with who have BPD symptoms have often experienced deep trauma in their life in particular the provocation to perform by caregivers. The intelligent child is often provoked to argue and debate with the parent. The attractive child is often provoked to manage her modesty and remain thin and attractive. The entertaining child is often provoked to regulate and manage the ever-changing moods of their caregivers.
This trauma can result in difficulties regulating emotions and interpersonal relationships. However, the misuse of the BPD diagnosis can absolve caregivers of their responsibility, attributing all challenges faced by individuals to their supposed pathology. This perpetuates the cycle of abuse and denies individuals the opportunity to heal and reconnect with their authentic selves. Care should address the person’s history without assuming it in advance. The examples above invite questions about how a child’s role can become an internal image: intelligent, attractive, entertaining, or responsible for another person’s feelings.
Clinicians also need to consider their own responses and expectations, rather than place the whole difficulty within the person seeking help. A diagnosis should support care and leave room for a person beyond the label.
Klein, M. (1946). Notes on Some Schizoid Mechanisms. In Envy and Gratitude and Other Works 1946–1963.
National Institute of Mental Health. Borderline Personality Disorder.