On the topic of mental disorders and responsibility—of late, I’ve been hearing several therapists repeat a couple things that bother me:
1) Borderline Personality Disorder is just as serious as Schizophrenia and sufferers of BPD should be given just as much clinical attention and services.
I have to say, no, BPD is not the same as schizophrenia and should not in fact be treated the in the same manner. Should medical professionals be told they need to treat sunburn the same way they treat cancer? I think not. Furthermore, I don’t know why we treat so many people whose primary presenting problem is BPD in the public mental health system intended for people with severe disabilities. The bulk of the empirical research seems to show that BPD is best treated in the community with an established and effective therapy such as Dialectical Behavioral Therapy or similar. Placing people with BPD in residential facilities for the severely disabled will only be detrimental for both the client and everyone else who lives or works at the facility.
2) People with BPD who behave manipulatively should not be blamed or expected to change because their behavior is avolitional.
I will agree that “blaming” the client is in no way helpful, nor will expecting someone with BPD to instantly change result in anything but frustration. However, it is simply false to say that someone with BPD has no ability to modulate mood or behavior. No human behavior short of reflexes or seizures are avolitional. Making false statements of this kind, even in apparent defense of people with serious disorders, only serves to increase the divide in understanding. It also takes away from the agency and empowerment of the client that we are trying to help. Someone with BPD is not helpless to change. Change can happen with trust and support as long as there is a real desire in the person to make a change. Setting clear but respectful limits helps too, because we all know that, like it or not, life has limits. It is not at all helpful to give the BPD patient the message that anything they do is okay just because they have a diagnosis. Such a message can be devastatingly harmful.
It might help to illustrate this issue. Take a look at this excerpt from a recent news article (well, it's news-ish, I guess, it's from The Sun):
A WOMAN has been jailed for cruelly imprisoning three young children in a disgusting room without clothes, food or water.
When police arrived at the house they found the bedroom they had been left in all day stank of urine, had no beds or furniture and had a bucket as a toilet.
The grandfather of one of the children today slammed sick
's 15-month jail term as too lenient. . . . Henderson
Penny Moreland, defending, said: "Most people will find this shocking and distressing. This has not borne out of pure malice or badness.
"She was deteriorating mentally and has a borderline personality disorder [sic]."
The defense attorney here is presenting what a certain ilk of therapists are trying to put out there, that someone with BPD cannot be held responsible for their behavior. I would say, yes, it is distressing. The defense states that the behavior was not malice or badness and seems to imply that the behavior cannot be malice or badness as long as the behavior is “explained” by a mental health disorder, in this case BPD. It seems to be an underlying tacit assumption that the categories of malicious behavior and symptomatic behavior are mutually exclusive. At the risk of blaming people with BPD for their own behaviors, I have to question the validity of this assumed dichotomy. Is it possible that someone’s behavior might be driven by BPD and that person is acting with malice?