Introduction
Borderline personality disorder (BPD), also known as emotionally unstable personality disorder, personality disorder with borderline pattern, or complex emotional needs, is a mental disorder characterised by intense and unstable emotions, impulsive behaviour, difficulties in relationships, and a distorted sense of self (American Psychiatric Association 2022). Rates of BPD in Ireland stand at approximately 1% of the population and at between at 1–2.5% of the population in the UK (Bourke et al., Reference Bourke, Murphy, Flynn, Kells, Joyce and Hurley2021; McManus et al., Reference McManus, Bebbington, Jenkins and Brugha2016).
Recent shifts in the understanding of personality disorders have moved from a categorical to a dimensional framework, recognising that personality disorders exist on a continuum with the general population (Monaghan and Bizumic Reference Monaghan and Bizumic2023; Pan and Wang Reference Pan and Wang2024; Skodol Reference Skodol2021). The dimensional approach suggests that rather than being qualitatively distinct entities, personality disorders represent extreme variants of normal personality traits that everyone possesses to some degree. For instance, traits such as emotional instability, impulsivity, and relationship difficulties can be present in the general population but manifest in more extreme and maladaptive ways in those diagnosed with BPD. This perspective, reflected in the latest ICD-11 classifications, emphasises the severity of functional impairment and combines specific maladaptive personality traits (World Health Organisation 2024). Understanding the impacts on recovery becomes even more crucial in this context, as treatment approaches must now address the broader spectrum of personality dysfunction and its varied manifestations.
BPD is one of the most stigmatised mental health disorders, with individuals diagnosed with the condition experiencing more stigma compared to people with other mental health conditions, such as obsessive-compulsive disorder, bipolar disorder, depression, and anxiety (Hazell et al., Reference Hazell, Berry, Bogen-Johnston and Banerjee2022; Klein et al., Reference Klein, Fairweather and Lawn2022; McManus et al., Reference McManus, Bebbington, Jenkins and Brugha2016; Sheppard et al., Reference Sheppard, Bizumic and Calear2023). Stigma is defined as labelling, stereotyping, discrimination, and social exclusion and can be operating at social, structural, and institutional levels (Link and Phelan Reference Link and Phelan2001). For those who experience serious mental illness including BPD, stigma often involves ’self-stigma’, the process by which negative societal attitudes are internalised, which can lead to low self-esteem, increased anxiety, and social exclusion (Bathje and Marston Reference Bathje, Marston and Teo2014; Dubreucq et al., Reference Dubreucq, Plasse and Franck2021; Subu et al., Reference Subu, Wati, Netrida, Priscilla, Dias, Abraham, Slewa-Younan and Al-Yateem2021). Furthermore, the diagnosis of BPD often exacerbates stigma, especially when trying to access health services or simply having the diagnosis on health records, with stigma regarding the nature and treatability of their problems in many healthcare settings due to the attitudes of many clinicians (Stiles et al., Reference Stiles, Batchelor, Gumley and Gajwani2023). Stigma has been identified as a significant barrier to recovery among people with BPD (Carmel et al., Reference Carmel, Torres, Chalker and Comtois2018).
Engagement in compassion, understood as a sense of empathy and demonstration of kindness to oneself or between others, has been shown to provide mental health service users with a sense of purpose, support recovery, and enhance quality of life (Flett Reference Flett2018; Spandler and Stickley Reference Spandler and Stickley2011). Engagement in compassionate acts, whether directed towards oneself or others, may support personal recovery for those with mental health conditions, defined as one’s capacity to live a full, meaningful life of one’s choosing despite the limitations imposed by symptoms (Anthony Reference Anthony1993; Jordan et al., Reference Jordan, Davidson and Bellamy2022a; Reference Jordan, Grazioplene, Florence, Hammer, Funaro, Davidson and Bellamy2022b). Personal recovery is different for everyone, and for individuals with BPD, it has been found that key goals include reducing symptoms, improving well-being, enhancing interpersonal relationships, and developing a greater sense of self (Ng et al., Reference Ng, Carter, Bourke and Grenyer2019a; Reference Ng, Townsend, Miller, Jewell and Grenyer2019b). Unfortunately, some studies suggest that people with BPD may be less inclined to experience self-compassion or engage in compassionate acts towards others (Fagan et al., Reference Fagan, Hodge and Morris2022). Much research examining why this discrepancy exists has focused on understanding cognitive, motivational, or biological factors (Grzegorzewski et al., Reference Grzegorzewski, Kulesza, Pluta, Iqbal and Kucharska2019; Saunders et al., Reference Saunders, Goodwin and Rogers2015). Additionally, a high proportion of people with BPD have experienced childhood trauma, which profoundly affects their self-understanding. Some conceptualisations of BPD recognise that individuals often struggle with asking for their needs to be met, partly because their needs were not met as children, making self-compassion a challenging concept for them to grasp and practice (Ng et al., Reference Ng, Bourke and Grenyer2016). Conversely, the role of stigma in disempowering or dissuading people with BPD from having self-compassion or engaging in compassionate acts has received no attention.
Despite extensive research, legislation, and training, which highlight the expectations for clinicians to demonstrate compassion to their service users with BPD, there is often a lack of literature focused on compassionate acts among people with BPD themselves (Geller Reference Geller1993; Head and Strand Reference Head and Strand2000; Kemp et al., Reference Kemp, Zhang, Inglis, Wiljer, Sockalingam, Crawford, Lo, Charow, Munnery, Singh Takhar and Strudwick2020; Rooney Reference Rooney2020; Royal College of Psychiatrists 2015). This knowledge gap exemplifies a double standard in which people with BPD are unfairly burdened with the responsibility of navigating their symptoms in isolation, without recognition of the societal barriers and systemic challenges they may encounter in their efforts to engage in compassionate behaviour and be compassionate to themselves. This knowledge gap may decentre people with BPD within clinical care and violate key principles of recovery-oriented care (Davidson et al., Reference Davidson, Tondora, Pavlo and Stanhope2017).
Given the potential for compassionate acts to support personal recovery and improve the well-being of other people, it is crucial to address the stigma that disempowers people with BPD from engaging in these acts. Doing so will generate knowledge that can be used to strengthen the foundations of recovery-oriented care. This perspective piece explores the potential relationship between stigma and compassion among people with BPD.
Stigma
Link and Phelan (Reference Link and Phelan2001) define stigma as comprising four interrelated processes: labelling human differences, associating them with negative stereotypes, creating divisions between those labelled and not labelled, and experiencing reduced status and discrimination. In all cases, power must be exerted over the stigmatised party (Link and Phelan Reference Link and Phelan2001). This definition highlights the interconnected components of stigma and its manifestation in attitudes, behaviours, and social structures.
In the context of BPD, stigma manifests through misconceptions and negative attitudes that surround the diagnosis. Link and Phelan’s foundational theory was built upon by Corrigan, evolving into conceptions of public, structural, and institutional and self-stigma (Corrigan et al., Reference Corrigan, Larson and Rüsch2009; Corrigan and Rao Reference Corrigan and Rao2012; Corrigan et al., Reference Corrigan, Druss and Perlick2014; Corrigan and Watson Reference Corrigan and Watson2002). By understanding how stigma is perpetuated at different levels, multiple stakeholders can develop interventions targeting specific dimensions of stigma to promote social inclusion, equitable access to resources, and improved well-being for stigmatised people. Corrigan’s model has been widely applied in research examining people’s access to, engagement with, experiences of, and discrimination within mental healthcare (Corrigan et al., Reference Corrigan, Druss and Perlick2014; Pattyn et al., Reference Pattyn, Verhaeghe, Sercu and Bracke2014; Psychiatry.org, 2024; Rössler Reference Rössler2016; Rüsch et al., Reference Rüsch, Angermeyer and Corrigan2005). Corrigan’s model has also been extensively applied to understand experiences of stigma among people with BPD (Ahmed et al. Reference Ahmed, Newman and Yalch2021; Bonnington and Rose Reference Bonnington and Rose2014; Sheppard et al., Reference Sheppard, Bizumic and Calear2023).
Public stigma
Public stigma is present in attitudes and beliefs held by the general public towards stigmatised people and can manifest as social rejection, discrimination, and withdrawal of help and support (Corrigan and Watson Reference Corrigan and Watson2002). Examples of public stigma experienced by people with BPD include physical and psychological violence, including language which can be considered ‘violent’ or ‘harmful’, as well as violent force, and forceful invasions of privacy from caretakers (Bonnington and Rose Reference Bonnington and Rose2014). Public stigma may lead people with BPD to be ‘othered’ in social situations, with their viewpoints, opinions, and behaviours being misunderstood or dismissed because of pathologisations (Bonnington and Rose Reference Bonnington and Rose2014). A recent example of how public stigma is perpetuated was during the Depp versus Heard trial, during which public attention was brought to BPD through the media, not all of which was positive, with numerous publications linking BPD to erratic, violent, and abusive behaviours (King Reference King2022; Sheppard et al., Reference Sheppard, Bizumic and Calear2023). Although the general population is not ‘afraid’ of individuals with BPD, it has been noted that people will ‘keep their distance’, with the general belief that individuals with BPD need ‘re-education’ or to put more effort into themselves to overcome their personality ‘defects’ (Ociskova et al., Reference Ociskova, Prasko, Vanek, Nesnidal, Sollar and Slepecky2023). This perception contributes to the stigma surrounding BPD, portraying it as a moral failing rather than a mental disorder. Whilst the public stigma related to BPD increases the challenge of interpersonal relationships for individuals, it has also been suggested that the stereotypes and prejudice of the general public become ingrained in public and institutional policies (Kealy and Ogrodniczuk Reference Kealy and Ogrodniczuk2010; Warne and McAndrew Reference Warne and McAndrew2005).
Structural and institutional stigma
Structural stigma arises from societal structures, policies, or practices, while institutional stigma is perpetuated by the ethos and policies of institutions like healthcare providers. These forms of stigma are evident in the inadequate healthcare many people with BPD receive. Diagnostic challenges are common, with some clinicians questioning the legitimacy of BPD or viewing it as an ‘untreatable’ disorder. This scepticism can result in misdiagnoses or no diagnosis at all, depriving service users of appropriate, evidence-based treatments (Klein et al., Reference Klein, Fairweather and Lawn2022; Ociskova et al., Reference Ociskova, Prasko, Vanek, Nesnidal, Sollar and Slepecky2023).
Furthermore, service users with BPD often face negative biases from healthcare professionals who perceive them as difficult to engage with compared to other mental health conditions. Studies indicate that clinicians frequently hold more negative views of people with BPD than those with disorders like schizophrenia (James and Cowman Reference James and Cowman2007; Knaak et al., Reference Knaak, Szeto, Fitch, Modgill and Patten2015). The recent ICD-11 reclassification, which groups various personality disorders under a single diagnosis of ‘personality disorder’ with scaled severities, may exacerbate these issues by further stigmatising people previously diagnosed with specific disorders (World Health Organisation 2024).
In crisis situations, clinicians sometimes describe service users with BPD as ‘acting out’ or engaging in ‘attention-seeking’ behaviours, leading to inadequate care and negative interactions with service users and their families (Day et al., Reference Day, Hunt, Cortis‐Jones and Grenyer2018). These judgements can create feelings of blame, hopelessness, and isolation among service users and their loved ones (Warrender et al., Reference Warrender, Bain, Murray and Kennedy2020). Families of service users with BPD are often reluctant to discuss the diagnosis or encourage seeking help due to stigma, and some may even isolate the affected individual to avoid societal judgement (Fossati and Somma Reference Fossati and Somma2018; Grambal et al., Reference Grambal, Prasko, Ociskova, Slepecky, Kotianova, Sedlackova, Zatkova, Kasalova and Kamaradova2017; Kirtley et al., Reference Kirtley, Chiocchi, Cole and Sampson2019). This contributes to delayed and ineffective treatments (Ring and Lawn Reference Ring and Lawn2019).
Institutional stigma also manifests in how service users with BPD view mental healthcare professionals. Some individuals with BPD hold stereotypical and negative views, categorising psychiatrists in derogatory terms based on their experiences, which can deter them from seeking help (Ociskova et al., Reference Ociskova, Prasko, Vanek, Nesnidal, Sollar and Slepecky2023). These negative perceptions can create significant barriers to care, fostering mistrust and discouraging open communication, essential for effective treatment and recovery (Ebsworth and Foster Reference Ebsworth and Foster2017; Njaka et al., Reference Njaka, Ogbodo, Okpua and Uwa2023; Vayshenker et al., Reference Vayshenker, Deluca, Bustle and Yanos2018).
If clinicians dismiss a person with BPD’s concerns as ignorant or media-influenced rather than valid reflections of personal experiences, this may lead to further negative attitudes and impatience towards service users with BPD. Such dynamics can make service users with BPD feel marginalised and misunderstood, perpetuating a cycle of negative experiences and attitudes. This may erode trust in the mental healthcare system, making people with BPD less likely to voice their needs or seek help in the future, ultimately harming their recovery (Rojas et al., Reference Rojas, Martínez, Martínez, Franco and Jiménez-Molina2019).
The lack of empathy and compassion resulting from these forms of stigma can hinder effective clinical interactions. When service users feel seen as ignorant, they may withdraw, reducing the chances for constructive dialogue and support. Similarly, clinicians with negative views of service users with BPD may struggle to provide the necessary empathetic care, leading to a hostile or indifferent treatment environment. This may further undermine patient recovery and satisfaction with mental health services (Anandan et al., Reference Anandan, Cross and Olasoji2024; Rojas et al., Reference Rojas, Martínez, Martínez, Franco and Jiménez-Molina2019; Román-Sánchez et al., Reference Román-Sánchez, Paramio-Cuevas, Paloma-Castro, Palazón-Fernández, Lepiani-Díaz, De La Fuente Rodríguez and López-Millán2022).
Whether or not service users’ negative attitudes towards mental healthcare providers are justified, this stigma significantly affects their recovery. People with BPD may avoid seeking help due to these prejudices, and professionals facing stigma may experience burnout and job dissatisfaction, potentially reducing the quality of care (Picco et al., Reference Picco, Chang, Abdin, Chua, Yuan, Vaingankar, Ong, Yow, Chua, Chong and Subramaniam2019; Vayshenker et al., Reference Vayshenker, Deluca, Bustle and Yanos2018; Zaman et al. Reference Zaman, Mujahid, Ahmed, Mahmud, Naeem, Riaz, Ullah and Cox2022). This complex interplay of stigmas creates barriers to effective treatment and recovery, highlighting the need for systemic change in mental healthcare.
Self-stigma
Self-stigma occurs when negative societal attitudes become internalised, a process that is prevalent for those with ‘serious mental illnesses’(Corrigan and Rao Reference Corrigan and Rao2012; Dubreucq et al., Reference Dubreucq, Plasse and Franck2021). People with BPD report higher levels of self-stigma compared to people with other mental disorders (Grambal et al., Reference Grambal, Prasko, Kamaradova, Latalova, Holubova, Marackova, Ociskova and Slepecky2016; Sheehan et al., Reference Sheehan, Nieweglowski and Corrigan2016), which can be seen as reflecting the societal and institutional prejudices faced from outside sources (Grambal et al., Reference Grambal, Prasko, Kamaradova, Latalova, Holubova, Marackova, Ociskova and Slepecky2016; Quenneville et al., Reference Quenneville, Badoud, Nicastro, Jermann, Favre, Kung, Euler, Perroud and Richard-Lepouriel2020). Self-stigma may also be considered intrinsic to the diagnostic symptoms of BPD, which include a pervasive sense of low self-worth and identity disturbance (American Psychiatric Association 2022). This self-stigma is related to lower self-esteem, lack of social support, less engagement with regular care, lower quality of life, and higher rates of symptomology, further perpetuating the severity of the condition (Grambal et al., Reference Grambal, Prasko, Kamaradova, Latalova, Holubova, Marackova, Ociskova and Slepecky2016; Koivisto et al., Reference Koivisto, Melartin and Lindeman2022; Quenneville et al., Reference Quenneville, Badoud, Nicastro, Jermann, Favre, Kung, Euler, Perroud and Richard-Lepouriel2020). More serious symptoms of BPD, including self-harm and suicidality, can then lead individuals to access emergency healthcare, where they again are more likely than others to face institutional stigma and substandard care. This leads to a cycle of stigma at many levels, from people, institutions, and individuals with BPD towards themselves.
How stigma acts as a barrier to compassionate acts for people with BPD
The stigma surrounding BPD significantly amplifies the barriers individuals face in engaging in compassionate acts, interacting with others, and pursuing recovery (Fagan et al., Reference Fagan, Hodge and Morris2022; Knaak et al., Reference Knaak, Szeto, Fitch, Modgill and Patten2015; Naismith et al., Reference Naismith, Kerr, Mwale and Feigenbaum2019). Each source of stigma – public, structural, institutional, and self-stigma – intersects in complex ways, shaping the challenges people with BPD experience in offering and receiving compassion. Despite extensive research on barriers to altruism in the general population and among individuals with mental health conditions (Banjeree and Hammond Reference Banjeree and Hammond2022; Sandstrom and Boothby Reference Sandstrom and Boothby2021), limited research has explored the intersection between these barriers and the stigma experienced by people with BPD when attempting to engage in compassionate actions (Salaheddin and Mason Reference Salaheddin and Mason2016; Velasco et al., Reference Velasco, Cruz, Billings, Jimenez and Rowe2020). Understanding how these elements connect could aid in understanding the difficulties individuals with BPD face in engaging in compassionate acts, helping to develop new and effective interventions to alleviate these challenges and enhance recovery.
Some of the most common barriers for the general population in engaging in compassionate acts are a lack of opportunity and fears of what may happen during an interaction, such as being perceived as weak, misunderstood, or disliked (Banjeree and Hammond Reference Banjeree and Hammond2022; Sandstrom and Boothby Reference Sandstrom and Boothby2021). These concerns are often amplified by the symptoms and stigma experienced by people with BPD and are closely linked with low self-esteem, anxiety, and unstable self-evaluations and connections to others (Corrigan, et al., Reference Corrigan, Larson and Rüsch2009; Grambal, et al., Reference Grambal, Prasko, Kamaradova, Latalova, Holubova, Marackova, Ociskova and Slepecky2016). This amplification stems from the pervasive nature of BPD stigma, which influences both internalised and external perspectives on social interaction, fostering environments of heightened fear and withdrawal (Klein et al., Reference Klein, Fairweather and Lawn2022; Naismith et al., Reference Naismith, Kerr, Mwale and Feigenbaum2019).
For people with BPD, heightened negative feelings and uncertainties surrounding social interactions may increase their fears of negative outcomes when engaging in compassionate acts. Individuals with BPD often experience heightened rejection sensitivity, which further amplifies their negative feelings and uncertainties in social interactions (Berenson et al., Reference Berenson, Downey, Rafaeli, Coifman and Paquin2011). This heightened sensitivity can lead to increased fears of potential negative outcomes, such as rejection, judgement, or misunderstanding (Bungert et al., Reference Bungert, Liebke, Thome, Haeussler, Bohus and Lis2015). Research suggests that individuals with BPD may perceive social cues more negatively and anticipate rejection more readily than those without the disorder (Foxhall et al., Reference Foxhall, Hamilton-Giachritsis and Button2019). Due to these symptoms, individuals with BPD may be more reluctant to engage in compassionate acts, which amplify the barriers the general population faces to compassionate engagement.
Similarly, stigma often leads to exclusionary behaviours, such as social withdrawal and limiting contact with friends or family, causing people to become less connected with their communities, having a negative impact on recovery (Liamputtong and Rice Reference Liamputtong, Rice and Liamputtong2021). For people with BPD, intense and unstable relationships are a key symptom that can complicate interpersonal connections. As well as stigma surrounding the disorder leading to social exclusion, the unstable relationships people with BPD can face may lead to a significant number of people with the condition being more withdrawn and less socially connected than people with other mental disorders (Beeney et al., Reference Beeney, Hallquist, Clifton, Lazarus and Pilkonis2018). This limited social connectedness not only affects the individual’s emotional well-being but also reduces opportunities for altruistic behaviour, which is often reciprocated within close-knit communities (Rowe and Davidson Reference Rowe and Davidson2016).
This ‘maladaptive’ behaviour from both the symptoms and the self-stigma of BPD can lead to further public stigma and discrimination, when people do not socialise ‘as expected to’ by others, resulting in a cycle of ’social stigma, self-stigma, and social maladaptation’ (Grambal, et al., Reference Grambal, Prasko, Kamaradova, Latalova, Holubova, Marackova, Ociskova and Slepecky2016, p. 2440). This once again demonstrates how stigma can amplify the barriers to engaging in compassionate acts faced by the non-pathologised population for people with BPD. The combined effect of these factors means that individuals with BPD can be caught in a cycle where their condition and the accompanying stigma reinforce each other, potentially making it even more challenging to engage compassionately and socially. When people with BPD withdraw from social situations, they may not only miss out on the chance to perform compassionate acts but also on opportunities to receive compassion from others. The fear of rejection and misunderstanding can prevent them from seeking or accepting help, leading to a lack of social support and furthering their isolation. Over time, this isolation can contribute to feelings of emptiness and worthlessness, which may further diminish their ability to perceive themselves as valuable contributors within their communities (Crowe Reference Crowe2004; Miller et al., Reference Miller, Townsend and Grenyer2021). This social isolation significantly impedes recovery, as living with, contributing to, and being valued by a community is fundamental to the healing process (Rowe and Davidson Reference Rowe and Davidson2016).
Institutional stigma adds another layer of complexity. Within healthcare systems, service users with BPD are frequently labelled as ‘attention-seeking’, ‘manipulative’, or ‘difficult to treat’ (Krawitz Reference Krawitz2004; Ring & Lawn, Reference Ring and Lawn2019). Such labels not only undermine the therapeutic relationship but also contribute to individuals with BPD internalising negative beliefs about themselves (Fagan et al., Reference Fagan, Hodge and Morris2022; Grambal et al., Reference Grambal, Prasko, Kamaradova, Latalova, Holubova, Marackova, Ociskova and Slepecky2016; Klein et al., Reference Klein, Fairweather and Lawn2022; Naismith et al., Reference Naismith, Kerr, Mwale and Feigenbaum2019). This institutional stigma can reinforce fears of compassion and hinder individuals from engaging in acts of altruism or self-compassion (Fagan et al., Reference Fagan, Hodge and Morris2022; Gratz et al., Reference Gratz, Myntti, Mann, Vidaña and Tull2022). When individuals are repeatedly dismissed or judged by those expected to offer support, their ability to trust others diminishes, creating additional barriers to recovery (Fagan et al., Reference Fagan, Hodge and Morris2022; Naismith et al., Reference Naismith, Kerr, Mwale and Feigenbaum2019). Furthermore, these experiences often lead individuals with BPD to disengage from formal healthcare services, perpetuating untreated symptoms and reducing their access to interventions that could mitigate the impact of stigma on compassionate behaviours (Ring & Lawn, Reference Ring and Lawn2019; Sheppard et al., Reference Sheppard, Bizumic and Calear2023).
Therefore, individuals with BPD may be more reluctant to engage in compassionate acts, due to heightened fears of rejection, judgement, or misunderstanding. This self-stigma could lead to a cycle in which negative self-perception and anticipated negative social feedback discourage individuals with BPD from participating in acts that could enhance their social well-being and recovery.
BPD, stigma, and recovery
Recent research has identified key processes in people’s recovery journeys, including overcoming ambivalence and committing to action, transitioning from shame to self-acceptance and compassion, and moving from distrust and defensiveness to opening up to others (Katsakou et al., Reference Katsakou, Pistrang, Barnicot, White and Priebe2019). However, these processes are significantly influenced by structural and institutional stigma within mental health services, particularly towards people with BPD.
Service users with BPD may only be able to overcome ambivalence and commit to action if practitioners are willing to provide the necessary support, such as regular specialist therapies (Katsakou et al., Reference Katsakou, Pistrang, Barnicot, White and Priebe2019). Structural stigma can manifest in practitioners’ reluctance to treat BPD due to the perceived complexity of the disorder and the negative stereotypes associated with it (Klein et al., Reference Klein, Fairweather and Lawn2022). This reluctance may limit access to specialised BPD interventions that are crucial for facilitating these key recovery processes. Without dedicated support, people with BPD may struggle to engage in their recovery journey, reinforcing a cycle of ambivalence and inaction.
Transitioning from shame to self-acceptance and compassion has also been found to be a critical step in recovery (Katsakou et al., Reference Katsakou, Pistrang, Barnicot, White and Priebe2019). However, this process can be hindered by the lack of empathetic and compassionate care from practitioners influenced by institutional stigma (Creurer Reference Creurer2016). When practitioners hold biased views about BPD, their interactions may lack the professional empathy and understanding needed to help people with BPD develop self-compassion through high-quality, reliable healthcare (Friesen et al., Reference Friesen, Gaine, Klaver, Burback, Agyapong and Carrà2022). This lack of supportive care can lead to further feelings of shame and hinder a service user’s development of self-acceptance.
For people with BPD, moving from distrust and defensiveness to opening up to others requires a safe and supportive therapeutic environment (Katsakou et al., Reference Katsakou, Pistrang, Barnicot, White and Priebe2019). However, structural stigma can create barriers to creating and entering these types of environments. If mental healthcare practitioners hold negative attitudes towards service users with BPD or are not willing to treat the condition, distrust between service users and practitioners can occur (Sulzer Reference Sulzer2015). The initial emotional shutdown often experienced by service users when receiving compassionate care could also reinforce practitioners’ negative stereotypes of people with BPD, leading to a cycle where practitioners believe service users with BPD are difficult to work with (Fagan et al., Reference Fagan, Hodge and Morris2022; Soler et al., Reference Soler, Casellas-Pujol, Pascual, Schmidt, Domínguez-Clavé, Cebolla, Alvear, Muro and Elices2022). This perception can result in less empathetic care, leading to further defensiveness and distrust.
Furthermore, BPD may not always be prioritised in clinical settings, where clinicians may inadvertently rank disorders based on perceived severity or treatability, further marginalising those with BPD within resource-constrained systems (Klein et al., Reference Klein, Fairweather and Lawn2022; Sulzer Reference Sulzer2015). These factors combine to create significant barriers to compassionate and effective treatment for individuals with BPD, exacerbating their experiences of stigma and hindering their access to essential mental health support.
Practical mental healthcare challenges include integrating self-compassion into common therapeutic interventions (Katsakou et al., Reference Katsakou, Pistrang, Barnicot, White and Priebe2019). Despite the initial emotional shutdown that can be triggered by receiving compassion, interventions focusing on self-compassion skills have been found to positively transform self-perception and aid recovery (Fagan et al., Reference Fagan, Hodge and Morris2022; Soler et al., Reference Soler, Casellas-Pujol, Pascual, Schmidt, Domínguez-Clavé, Cebolla, Alvear, Muro and Elices2022). However, for these interventions to be effective, practitioners need to approach their work with minimal bias and stigma that are often prevalent in mental healthcare for BPD. Without this shift, people with BPD will continue to face significant barriers in accessing the compassionate care they need, hindering their recovery process.
Understanding and addressing these barriers is crucial for enhancing the effectiveness of interventions aimed at promoting compassionate engagement among people with BPD. By incorporating insights from recent research, interventions can be tailored to address the unique challenges faced by people with BPD, ultimately facilitating their recovery journey and promoting overall well-being.
Three ecologies of stigma have been explored in this paper, each of which requires a nuanced and tailored approach to interventions to tackle stigma and encourage compassion: structural and institutional stigma, self-stigma, and public stigma. Structural and institutional stigma can be addressed through public awareness campaigns and training programmes for healthcare providers, by improving understanding and reducing biases, thereby fostering a more supportive environment and encouraging compassionate engagement. Self-stigma can be mitigated using compassion-focused therapy, which helps individuals with BPD develop self-compassion through mindfulness practices, self-compassion exercises, and group therapy sessions, enabling them to engage more compassionately with themselves and others. Public stigma can be reduced through educational programs, media campaigns, and community outreach, which challenge stereotypes, promote understanding, and reduce fear and misunderstanding about BPD, encouraging compassionate interactions within the broader community. By targeting these levels of stigma through tailored interventions, a supportive environment can be created that fosters compassionate engagement and supports the recovery and well-being of individuals with BPD.
Conclusion
Research in this area has the potential to bridge a critical gap in the literature by providing insights into the factors that influence individuals with BPD to engage in compassionate acts. Engaging in these acts can support mental health recovery, making it crucial to understand these influencing factors to develop interventions that promote compassion and well-being. Focusing on this research and intervention development can address public stigma, institutional stigma, and self-stigma, enhancing access to supportive resources and improving outcomes for individuals with BPD. However, failure to prioritise these actions risks perpetuating stigma within mental health services, in the broader public, and in individuals, potentially compounding trauma, worsening prognosis, and increasing the risk of negative outcomes among those with BPD. Prioritising these actions can alleviate stigma, support mental health recovery, and contribute to the overall advancement of mental health care and compassionate support systems. This holistic approach not only benefits individuals with BPD but also fosters a more supportive and understanding community.
Financial support
This work was supported by the Hilary Green Studentship.
Competing interests
The authors declare none.
Ethical standard
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008. Ethical approval was not required for the publication of this Perspective Piece.
