Last year, a woman, Helen Millard, died after being found hanging in a psychiatric ward bathroom. An inquest this week reported that when she had first been admitted, she was under constant observation. But on this day, she was able to spend thirty minutes in a bathroom alone, unchecked, despite staff knowing she had been tying ligatures around her neck up to four times per day. Helen was obviously an amazing woman, "very loving and caring" and "hard-working, determined and very driven" as her husband tells us. Yet she was described as "manipulative", "argumentative" and "hostile" by nursing staff, not just as an idle aside, but in a formal statement. What in psychiatry makes it seem legitimate to speak that way about a struggling woman?
Helen had a diagnosis of 'emotionally unstable personality disorder', also referred to as 'borderline personality disorder' ('BPD'). 'BPD' is constructed as a syndrome characterised by things like a fear of abandonment, unstable relationships, extreme emotional turbulence, rage and disconnection. 'BPD' has always been a synonym for the 'difficult patient' in psychiatric-speak. Patients who are constructed as wilfully pitting staff members against one another - too sexual, too clever, too aware of their actions to deserve care, interest and respect. Angelina Jolie in 'Girl, Interrupted'. Glen Close in 'Fatal Attraction'. Wasting resources and messing with staff's heads deliberately.
There have been attempts to challenge these ideas. Feminist critiques of the lack of construct validity of the diagnosis. A 2003 government report rather optimistically titled 'Personality disorder: No longer a diagnosis of exclusion'. Current calls to frame 'BPD' as an illness like any other, or to change the label to one that sounds, well, nicer. But would these changes help? Was it not the (incorrect) idea that she was backed up by medical science, for example, that allowed the nurse to speak in the way she did?
For the label of 'BPD' shuts down our humane response. It allows staff to think and act through the kind of awful language lens used about Helen - to 'other'. Language, especially powerful language around diagnosis, can be dangerous. Consider a recent study. 265 clinicians were asked to watch a video of a woman presenting with 'panic disorder'. They then had to rate her presenting problems and prognosis. A third were just given her presenting problems, a third were given this plus a description consistent with 'BPD' and a further third that and the label 'past PD'. Those who were told the woman had a 'PD' were significantly more likely not just to give the woman a poor prognosis, but to actually describe the panic shown in the video in worse terms.
This matters not least as our sense of ourselves is constantly being constituted through how others experience and react to us, which we absorb and take in. If we are storied as 'manipulative' and 'needy', it can only reinforce our self-hate and the hellish lived reality psychiatry is supposed to be helping with. Worse, these judgement calls, which the diagnosis legitimise, all too often echo the attacks of the critical others who caused the problems in the first place - the abuser who said the patient-when-girl 'asked for it', who told her it was 'her fault' for being too alluring. The bully who said the patient-as-boy 'was a waste of space'. The should-of-been caregivers who neglected to see what was attempting to be communicated, leaving the patient-when-child even more alone.
In the UK, there are daily examples of the damaging effects of the idea 'personality disorder' is a thing. People presenting with self-harm told "it's your choice to die, there is nothing we can do" at the moment when someone, please, needs to believe for them that there can still be a life worth living for, the smallest slither of hope. Women whose self-harm injuries are not judged worthy of treatment because they are self-inflicted, with staff ringing up local hospitals to say "she has this diagnosis - don't treat her". Psychiatrists who, overtly, punish individuals that paramedics have 'forced' them to admit. Changing the label to a nicer sounding name, as some call for, will only slide these damaging set of value judgements and practices over onto a new term.
We do not need to be restricted by a seeming choice between an illness model or attribution to personality flaw. We can be capable, surely, of recognising that problems lie on a continuum, and that someone can deserve support, care, and treatment for a writ large manifestation of the dynamics of hate, love, rage, destruction and manipulation present in all of us. Perhaps even more so if we can truly acknowledge the consistent association between childhood abuse, neglect and trauma with this most problematic of labels.
We cannot claim that society has a greater mental health awareness, a new understanding of the extent of sexual abuse, when we tolerate traumatised individuals being morally judged, ignored and rejected for manifesting the sequelae of their distress in acute wards and mental health services up and down the country.
I intended to end this piece, by writing: 'For Helen, it is too late. For others, perhaps not'. But I have just been alerted to news of the death of another young woman, Victoria Halliday, her experiences also invalidated via the label of 'personality disorder'.
We must rally for something better, folks. And we must do it now.