An interesting recent article from Mad in America raises a fundamental question: Does the diagnosis of Borderline Personality Disorder (BPD) help us understand human suffering, or can it sometimes contribute to that suffering?
The article discusses a 2026 paper in the International Journal of Mental Health Nursing, which makes a strong argument for abolishing BPD as a diagnostic category. The authors suggest that the diagnosis is not simply a neutral description of a set of symptoms. Rather, it can reflect and reinforce broader cultural assumptions about what constitutes acceptable emotional expression, identity, relationships and behaviour.
Some of their arguments are:
• The pathologising of distress: Emotional intensity, relational difficulties, dependency and expressions of anger may be interpreted as symptoms of personality dysfunction, without adequately considering trauma, adversity and the circumstances in which these responses developed.
• The power of diagnostic labels: A BPD diagnosis can influence how professionals interpret a person’s behaviour. Expressions of distress may be seen as manipulation, resistance or attention-seeking, potentially undermining the person’s credibility and access to appropriate care.
• Gender, culture and neurodiversity: The authors question whether diagnostic criteria reflect culturally specific expectations about emotional regulation, attachment, identity and interpersonal behaviour. They also highlight the potential for autistic sensory distress and the effects of discrimination to be misunderstood through a BPD framework.
• The possibility of iatrogenic harm: Perhaps most concerning is the suggestion that the diagnosis itself can contribute to shame, stigma, exclusion and re-traumatisation. In some circumstances, the very system intended to provide care may inadvertently compound the person’s suffering.
The authors ultimately argue that we need to move towards approaches that prioritise relational safety, cultural responsiveness, sensory-informed care, lived experience and a more critical understanding of the power inherent in diagnostic systems.
There are some important questions worth considering before accepting the argument wholesale.
Does questioning the diagnosis mean abandoning the possibility that people experience relatively enduring patterns of emotional, interpersonal and behavioural difficulties that deserve recognition and treatment? Could we distinguish between the potential clinical usefulness of identifying patterns of distress and the potentially harmful consequences of attaching a particular diagnostic label? And what happens to the considerable body of therapeutic knowledge and practice developed around BPD, including approaches such as Dialectical Behaviour Therapy (DBT), and Schema Therapy? Can we retain what is helpful without necessarily retaining the diagnostic construct?
The most important thing for me: Are we sometimes so focused on identifying what is wrong within the individual that we fail to examine what has happened to them, the environment in which they live, and the systems within which they seek help?
I don’t think these questions have simple answers. Nor do I think that replacing one diagnostic label with another necessarily solves the problem. However, the article raises an important challenge for counsellors and mental health professionals: to remain curious about the explanatory frameworks we use, rather than allowing them to become unquestioned truths. Perhaps the most useful starting point is to remember that a diagnosis should serve the person and their therapeutic journey, not the other way around.
What do you think? Is BPD a useful clinical construct that needs more thoughtful application, or is the problem more fundamental, requiring us to rethink the diagnosis itself? And (there’s another article in this!): in how far should we perhaps let go of MANY of the DSM-5 diagnoses based on argument similar to the above ones???
Let me know!
Marc de Bruin is an ACA Level 4 counsellor, clinical supervisor (for both PACFA and ACA), university tutor, and former barrister-solicitor with over 20 years’ experience in counselling, supervision, and professional development. He is the founder of Counselling Supervision and Simplifying Life.
