Lost in Translation: A Reflection on the Label of BPD

Our team recently attended the International Society for the Study of Personality Disorders conference in Boston. This gathering reflects a value at Cornerstones of Maine and Rubedo Transitions. In the transitional living level of care, our goal is successful, sustainable independent living. To this end, it can be tempting to reduce the treatment process to rote skill-building. While that’s certainly an essential piece, it’s rarely that simple. As such, it feels important to us that we shine a clinical spotlight on the more hidden variables that might be holding a client or family system back from their goals. Just as skills aren’t the whole picture, neither is mood. In treatment, the architecture of our personalities deserves equal attention.

With too much frequency, the term ‘Borderline Personality Disorder’ is used obtusely. Once this label is conjured, we’re at risk of using it as an explanation in itself. The client is ‘borderline,’ so treatment becomes about crises, workbooks, and acronyms. The diagnosis becomes normative rather than informative. 

Our colleagues at ISSPD remind us that there’s a deeper level here. Personality ‘structure’ refers to how a person organizes their inner world, particularly under stress. It describes how emotions are regulated or dysregulated. Not just that they are. An object relations lens empowers us to understand how relationships are experienced and how a stable or unstable sense of self feels when things are uncertain or painful. 

This distinction matters because a diagnosis tells you what you are seeing, but the anatomy of the diagnosis helps explain why it is happening.

Many of the young adults we work with would not meet full criteria for Borderline Personality Disorder. Still, when under pressure, they may become flooded by emotion and lose the capacity for mentalization. When shame feels unbearable, rage isn’t far behind. An all too common pitfall is to treat these autonomic reactions as willful. If we succumb to this, treatment can rapidly derail toward power struggle. 

Diagnostic labels aren’t without their utility. Lest we be accused of our own ironic reactivity, we need not throw the baby out with the bathwater. Nevertheless, our clients are better served by helping them to comprehend their relationship with self and their relationship with relationships. Borderline personality structure develops over time, often in sensitive, perceptive individuals who learned early that closeness was unpredictable or that emotional needs came with consequences. (Parents, please pardon the implication. It takes a village.)

Seen this way, behaviors that frustrate families and providers might start to be understood differently. Avoidance isn’t always laziness. Intensity isn’t always manipulation. Sabotage isn’t strictly spite. All are efforts to maintain homeostatic security. It is what happens when a person does not yet have the capacity to hold conflicting feelings within themselves or integrate conflicting traits in others. 

As if this wasn’t complex enough, now add neurodivergence to the mix.

Clients with ASD, ADHD, and OCD have diagnostic profiles that bring another layer to this picture. (Don’t get me started on the problems with these labels as well. That’s another blog entry.) These clients have traits that shape how emotions are processed and how flexible a person can be in a given moment. When certain neurotypes interact with borderline personality structure, the result can be confounding. Not only for the support network, but for the client as well.

A neurodivergent young adult may rely heavily on predictability or cognitive control to stay regulated. When those pillars break down, emotional reactions can be intense and tough to organize. Without a structural understanding, support teams may see only defiance or rigidity, missing the underlying vulnerability driving the behavior. BPD or Autism? Fear or confusion? If both, we’ve got to be surgical in our conceptualization. 

Parents are too frequently handed these diagnoses without proper context, leaving them to wonder whether their child is simply resistant, unmotivated, or even beyond help. Neurodivergence with co-occurring borderline personality may mean their child’s struggles reflect an internal system that's working double time to solve two puzzles at once. Managing emotional intensity and navigating relational closeness are shared focuses in the venn diagram of clients with BPD and clients with Autism. However, the psychological predicates are wholly different. One leans developmental. One leans neurological.

If we have any chance of helping these clients to find their footholds, it will require us to remain curious, tolerate complexity, and resist the urge to simplify people when they become hard to understand. Borderline is not a verdict. It is a way of organizing experience. More importantly, it is subject to evolution when we take the time to really listen.