Mental disorder seen as ‘badness, not sickness’

NEW YORK CITY — Psychiatrists regularly get criticized for turning typical life problems into medical disorders. But in an odd reversal, many mental health clinicians are trying to transform one certified mental illness, borderline personality disorder, into a label for needy, manipulative people who don’t need treatment, a sociologist reported at the American Sociological Association’s annual meeting on August 11.

Patients with borderline personality disorder, unlike people with schizophrenia or other serious mental conditions, are often viewed by mental health providers as having cynically planned out rash acts and even suicide attempts, sociologist Sandra Sulzer of the University of North Carolina at Chapel Hill found in extensive interviews with 22 psychiatrists and psychologists in the United States.

The condition includes difficulty controlling emotions, intense but unstable relationships, recklessness, cutting and other acts of self-harm, along with attempted and completed suicides. Before Sulzer’s study, little was known about how mental health professionals discuss and deal with this troubling set of symptoms.

“Clinicians frequently view borderline personality disorder symptoms as signs of badness, not sickness, and as a code to route patients out of mental health care,” Sulzer said. That finding goes a long way toward explaining why many borderline personality disorder patients receive no treatment despite the availability of effective forms of psychotherapy (SN: 6/16/07, p. 374), she suggested.

Sulzer carried out her interviews of mental health workers shortly before the release of the latest manual of psychiatric disorders, the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5. Before its release, proposed revisions of the definition of borderline personality disorder created controversy among psychiatrists and members of the committee writing the revisions.

Sulzer doesn’t know whether inadequate training or other factors explain why only a couple of clinicians regarded borderline personality disorder patients as having a treatable mental condition.

Borderline personality disorder patients can indeed be frustrating to treat, remarked Jerome Wakefield, a social worker at New York University who has criticized DSM for incorporating normal forms of sadness into the definition of depression.

Still, Sulzer’s findings show that the boundary between frontline clinicians’ definitions of bad and mentally disordered behavior demand much closer scrutiny, Wakefield said.