by Dr Helen Stallman
Borderline Personality Disorder (BPD) has been plagued by long-standing misconceptions and stigmatisation. It is an illness labelled and portrayed as a personality issue rather than an illness caused by developmental competency deficits that result from interpersonal trauma. In the past, the psychiatric community’s observations took precedence over the experiences of consumers, leading to the label of Borderline Personality Disorder. However, contemporary practice, with a focus on the consumer, has illuminated the true nature of BPD and paved the way for improved care and more effective treatments that prioritise consumers’ needs. In this article, we will delve into the shift from labelling BPD as a personality problem to recognising it as a developmental competency deficit and emphasising the importance of consumer-centred care.
- BPD: A Developmental Competency Deficit
Historically, Borderline Personality Disorder was often seen as a flaw in an individual’s character or personality. People with BPD were unfairly stigmatised as being difficult, attention-seeking, or manipulative. Such misconceptions not only hindered understanding of the condition but also led to ineffective treatments and unnecessary suffering.
Today, mental health professionals understand that BPD primarily stems from developmental competency deficits, typically caused by interpersonal trauma during childhood or adolescence. It is essential to emphasise that developmental competency deficits are not a choice or a personality flaw; rather, they are a functional response to an unhealthy experience. Developing a healthy identity, emotional and behavioural regulation, and healthy interpersonal skills—developmental competencies—becomes challenging in an unhealthy social environment. Individuals learn to adapt and cope as best they can. Those with developmental competency deficits demonstrate exceptional resilience and problem-solving skills in spite of challenging environments.
However, exposure to dysfunctional social environments can take their toll including hypervigilance for threats, poor interpersonal skills to interact with healthy people, and overwhelming unpleasant emotions. Overwhelming distress—unpleasant emotions that exceed healthy coping—necessitates the use of unhealthy coping strategies. Recognising this fundamental aspect of developmental competency deficits is crucial for providing effective care.
Principles of Care
There are four steps to consumer-centred care for people with developmental competency deficits (including those labelled with BPD).
- Consumer-centred framework
Policies, procedures and practices should all be consumer-centred rather than clinician-focused. These recognise developmental competency deficits as an illness, not a personality characteristic. They demonstrate respect for the autonomy of healthcare consumers and align service delivery with the needs of each consumer rather than the other way around.
- Care Collaborate Connect for acute distress
Care, using the Care Collaborate Connect steps, is the consumer-centred intervention for anyone who is acutely distressed. This is used by family and friends, first aid responders, and healthcare providers to ensure care 24/7. Being the social or professional support for people with developmental competency deficits can also be overwhelming at times. Professional support also needs to be available to family, friends, and healthcare providers as needed.
Consumer-centred clinicians understand that unhealthy coping strategies (e.g., negative self-talk, harmful activities, social withdrawal, and suicidality) are normal human responses to overwhelming distress, rather than specific to an individual or developmental competency deficits.
- Biopsychosocial assessment
A comprehensive biopsychosocial assessment, as required for all health problems, is essential to identify the root causes of overwhelming distress. This assessment includes all modifiable domains of health and wellbeing: the environment, developmental competencies, sense of belonging, health behaviours (sleep, nutrition, physical activity), coping strategies, perception of innate resilience, and treatment of co-existing illnesses. Collaboration between the consumer, who possesses expertise about their life, challenges, needs, and goals, and the clinician, an expert in the science and psychotherapeutic processes, is key to treatment outcomes.
Consumer-centred clinicians recognise the difference between unpleasant emotions, overwhelming distress, and the underlying causes of overwhelming distress.
- Evidence-based treatment of illness
Treatment should be evidence-based and tailored to address the underlying drivers of overwhelming distress. For developmental competencies, effective treatments include longer-term psychodynamic therapy, schema therapy, and dialectical behaviour therapy. Relationship counselling can also help people with poor interpersonal skills form and maintain healthy relationships with others.
To ensure the quality of care and prevent harm, it is crucial to monitor treatment integrity and consumer healthcare experiences after each session and address deficiencies in care as soon as possible.
Borderline Personality Disorder is a misnomer for developmental competency deficits that frequently result in overwhelming distress and necessitate unhealthy coping. Developmental competency deficits, like all illnesses, should not be confused with personality. Developmental competency deficits stem from interpersonal trauma. This paradigm shift has opened the door to more effective consumer-centred care. With adequate support and evidence-based treatments, individuals labelled with BPD can acquire the experience and skills they missed out on to achieve developmental competencies—healthy identity, emotional and behavioural regulation, and interpersonal skills—leading to improved health and overall well-being.
Dr Helen Stallman is a leading expert in wellbeing, coping and suicide prevention. Her research has explored the intersection of health and wellbeing, challenging outdated constructs and advocating for an integrated perspective on wellbeing to prevent mental illness and suicide.