In this guest post, Charlotte (she/her), aged 28- feminist, adwoman, mental illness- shares her experiences of living with borderline personality disorder, amongst other diagnoses and conditions. 'For me, getting the BPD diagnosis was almost a relief', she writes, 'it finally made sense why I did the things I did and felt the way I felt. I think the emotions shared in Charlotte's writing will bring comfort to many people. 'From about the age of 12 I have suffered from an eating disorder, which was formally diagnosed along with depression and anxiety around the age of 18. I have been receiving (private) treatment on and off and have been under proper care for 7 years, since I was around 21 years old. For a long time I got my head around those given diagnosis but there was always a bit of me missing. I didn’t understand why I couldn’t deal (or even name) my emotions, I didn’t understand why I couldn’t build relationships, and I couldn’t understand why I was so afraid everyone hated me, and was going to leave me. For me, getting the BPD diagnosis was almost a relief. It finally made sense why I did the things I did and felt the way I felt. I believe that a lot of my problems with BPD have to do with the trauma I had in my upbringing, and thus most of my treatment has been around that. My therapist doesn’t focus on the diagnosis much, but more on the behaviours that I portray. I have undergone DBT [dialectical behaviour therapy], CBT [cognitive behaviour therapy] and am currently undergoing EMDR [eye movement desensitization and reprocessing therapy]. DBT has been helpful for me, and the tools that work for me, is something that I look back at on a daily basis. I believe many of my problems will stay with my life long, so for me its around knowing which tools to use when, and improving my day to day by keeping the behaviours at bay. EMDR has been a completely different story- as I am still undergoing it, I can’t give a full account. However, it has allowed me to process certain traumas already and I hope that it continues to do so, so that I can make peace with what happened and learn to move on. One of the main things I hope it improves is my terrible ability to build healthy attachments. Personally, I think there is a stigma around the diagnosis ‘personality disorder’ and often when I talk about my mental illnesses I find it easy to say eating disorder, anxiety disorder and depression, but I often leave out the last one, the BPD. I do hope I can become more certain of myself, less scared to say those words. It’s part of who I am, and I think it will be for a long time. One thing that I’ll never forget, and try to hold on to-- those with BPD feel a lot. You hurt a lot, but you also have a lot of love to give. And that is certainly true.' -- Charlotte, @charlottschreu -- Thank you so much Charlotte for sharing your experiences. Like you, I have always found it far harder to disclose BPD than any other diagnoses or conditions. Over time though, I have developed the confidence to say the words 'borderline personality disorder' out loud, so much so that I am mostly comfortable to speak about it. I love how you finish by expressing that people with BPD 'hurt a lot', but 'also have a lot to give'. I couldn't agree more. I really hope that your powerful words act as a reminder of inherent worth to anyone struggling with self-loathing today: you are worthy of care, respect and support. I wish you all the best Charlotte with your EMDR therapy and thank you again for sharing your feelings and experiences here today. You can learn more about Charlotte via Twitter @charlottschreu. If you enjoyed this guest post, you can read more guest posts here.

[This post talks a bit about my experience of being suicidal.] Normally I know exactly how I feel and can pinpoint why. However, at the moment I am struggling to figure out what I feel and understand what's causing my confusion. I've tried talking to people about it (my partner, some friends & my therapist), but my feelings have been difficult to articulate. Firstly, my life has come to a turning point after many years of not knowing how things would turn out. I have an amazing partner, a dog, a home, a job I love and my book is out in October. As I mentioned in previous posts, I spent a long time plagued with suicidal thoughts and thoughts of self-harm. I didn't know how life was going to pan out for me and I often feared the worst. After everything I've been through with my mental health problems, sometimes the very fact of being alive feels overwhelming. Living with a mental health condition can be traumatic in and of itself (and that's before I've even mentioned past trauma or the potential for traumatisation within the current mental health care system). At the moment, whenever I reflect on my position in life today I'm liable to feel overwhelmed and tearful. The feelings relating to my survival-- the joy and relief-- are so intense that they feel chaotic. I'm still figuring out what to do with these huge feelings, especially because they are mixed with pride which makes it all the more unsettling. Secondly, I have finally reached the stage where I talk-- to varying extents-- about my BPD in every area of my life: blog, family, friends and career. The last frontier for me was disclosing within my job as a teacher and I have finally crossed into that unknown territory. I was in the right place and made the right decision; the small handful of conversations I have had have been affirming and freeing. These conversations have made me feel like a whole person in the workplace, instead of the fragment I have always presented at work. Although showing this key part of my identity with select colleagues has been joyful and liberating, it has also made me feel very vulnerable. I have been confused about how to manage these mixed feelings of happiness and vulnerability. Disclosing so fully at work is new to me, so it's an odd feeling and I am self-conscious. Sometimes I'm at work and I think to myself: 'Rosie, I can't believe you did that and you are still safe here'. I remember the psychiatrist who diagnosed me and told me she wouldn't put BPD down in my medical notes and how terrified that made me. To be honest, it all feels a bit wild to be myself so openly today. The book, the blog, disclosing to my work. It's like I've jumped on the back of an untamed horse and I have no idea where it's going to take me. I just have to hold on tight, I guess. With this wind rushing through my hair, I have to admit though that it does feel pretty amazing. As you will know if you have been reading my blog for a while now, a key theme in my life has been silence. This is the case for many people with BPD I think: 'be quiet', 'don't cry', 'don't tell anyone your diagnosis', 'let's not put your diagnosis in your notes', 'stop talking about your problems'. I chose not to accept silence as my life's theme because deep down I knew that if I did, I couldn't survive. Expression has been my lifeblood. As I wrote in my poem, 'I am the bird with the broken beak, shut me up but I will find a way to speak'. My therapist asked me last week what would have happened to me if I hadn't expressed myself. Her question made me cry, but answering it was easy. I will let you fill in the blanks. My book is coming out in October and inside is everything I have ever wanted to say over the last seven years about my life with BPD. I really hope it helps some of you. For now though, I need to rest because there is so much going on in my mind to process, even though it's all positive.

'When people hear the term "personality disorder" they think it's something to do with your character.' I had a great time talking about borderline personality disorder (BPD) on Chris Young's Walk A Mile In My Shoes Podcast. I immensely enjoyed chatting with Chris who has a deep understanding of BPD given his own experiences of living with this diagnosis. Plus, we had a few laughs about some of the awkward (and terrible) attitudes we have both encountered. Thank you so much Chris for having me on Walk A Mile In My Shoes. Chris Young is the author of 'Walk A Mile' which is available on Amazon and the host of Walk A Mile In My Shoes podcast. You can read more about Chris' amazing work to dismantle mental health stigma by walking and talking via his Facebook group and on Twitter @walkamileuk .

*This post discusses suicidal thoughts so please take care if you might find it distressing.* Although I still have fleeting suicidal thoughts every now and again during of extreme stress, several years have now passed during which I haven't had daily suicidal thoughts. For many years, it was normal for me go to sleep each day feeling so frightened, alone and despairing that my final thought before falling asleep was: could I take another day of emotional agony? For a long time, my response to any and all stressors-- anything I perceived as conflict or criticism-- was suicidal thought: 'I should die', 'I deserve to die', 'I can't live like this'. I think my response was a mark of the deep emotional pain I felt. I felt this agony often multiple times a day, most days. I didn't want to upset others or let anyone down, so I got really good at hiding how I felt. For someone who had no affinity for acting, I became a solid actress. I turned to self-harm because it felt like a release of painful emotions and it was helpful for social functioning. I found that I could stop my tears or outward displays of emotions if I translated them into a physical pain. Of course self-harming wasn't helpful for me as a person or my wellbeing because every time time I hurt myself, I reinforced the things I felt I was: shameful, bad, horrible, disgusting, worthless. It would not be fair to blame or shame myself for what I did to myself. I didn't know how else to cope; in those times I felt as though I had no other options. I wish everyone understood that. Today I know that I didn't deserve to feel that fear, loneliness and despair that incited my relentless suicidal thoughts. I didn't deserve to be in buried so deep in my problems. Nor was it my fault that I turned to self-harm. I needed help. I waited for help. At times I asked for support. There were many instances when I ought to have been given help, but I didn't get it. I didn't deserve to bear that burden of suicidal thoughts and self-harm. If you can relate to my experience, please know you don't deserve that burden either. I am writing this because I am no longer in the place. I am so far from that scary world where each new day feels like a threat. I no longer walk streets crying in the dark, I don't think about suicide like other people think about what to have for dinner, I don't turn up at A&E sobbing for help. The past me-- the me who did all of these things-- would find it surprising to know that this time passed. I wish I could have told the past me. Although if I did, I bet she wouldn't believe me. People who feel hopeless often find it difficult to feel hopeful. If you are wondering how much longer you can cope with your agony, please know that there really can come a time when you will look back at a past you and see how things can change. I really want you to give your future self that chance. Hope is not something that needs to be strong. It doesn't need to be something you need to permanently hold onto. You can pass it to other people to hold, whilst you feel hopeless. Hope can flicker like a flame in the wind. So can hopelessness. They both can come and go. If your hope has gone right now, it will come back. It's a matter of waiting. As hard as that may be. Please wait. *** I guess I just want to say, if you are feeling as scared, hopeless and alone as I once did, this time can pass. The past me didn't know that, but the present me does. I am glad to know this because I am here, alive with my happy life. I am here right now holding onto hope for you, until you can hold it in your own hands. - Rosie

I have been thinking about admiration quite a bit lately because my admiration for a small number of people has been sky rocketing. Admiration is something I have never shied away from. Since I was little, admiring people has pushed me forward in life and helped me live more closely to my values. When I was a primary-aged child, I found children's authors and illustrators so inspiring that I was writing and drawing all the time. The teenage me looked up to anyone with a colourful and creative style (whether their art, make-up or clothes), TV adventurers and documentary makers who travelled across the globe to meet people and see places, as well as individuals who dared to speak up about injustice and stand up for themselves or others. In my early twenties, finding my feet in work and relationships, I found admiration helpful for forming my identity, giving me direction and strengthening my determination. In times of crisis, admiration has made me resourceful. Asking myself what an admired person would do under these circumstances can forge resilience and help in a search for solutions. Lately though, I have found myself admiring a small number of people so much that I have to ask: is admiration actually helpful? Before I try to answer that question though, let's take a closer look at admiration. Admiration is a social emotion (that is, an emotion felt in the context of other people's thoughts, feelings and behaviours, such as shame, embarrassment, guilt or envy). Admiration is usually associated with liking and respecting someone for who they are or what they do; being in awe of, or admiring, their abilities or their character. In my opinion, admiration tends to happen when we see a quality within someone that we feel is worthy of deep respect and that is the result of skill, talent, strength or some other positive quality. I think admiring someone often involves thoughts like: 'wow, how do they do _______ so well?'. For me, thoughts that follow are usually curious: 'How did they get so good at _______?' 'Where did they learn how to ________?' or 'I wonder how I could improve my _______?' Admiration for me causes intrigue: I want to know more about the qualities, skills or abilities that I find admirable. For that reason, admiration inspires me, impels me to learn and moves me closer towards my goals. However, I reckon that admiration is a close sister emotion of envy. Envy (another social emotion) is when we long, often desperately, for something that someone has that we don't have. Envy is usually associated with uncomfortable feelings: a twinge or a pang of envy. This emotion is not to be confused with jealousy though. Jealousy, also a social emotion, is when we fear something we have may be taken from us by someone else i.e. feeling jealous of the new person in class or at the office because you fear they may 'steal' friends or opportunities. Urges associated with jealousy are usually to control, protect, or fight for what we have. By contrast, envy is often accompanied by the urge to strive for the thing that someone else has that we want or emulate (copy) the person that we are envious of. Although jealousy and envy tend to get negative press, in the right contexts and in sensible proportions, both of these emotions can be helpful; they can make us work for things we want, put the effort in, or win competitions etc. After all, each emotion has evolved for a reason and has a purpose (have a look DBT Skills Training Handouts & Worksheets by Marsha M. Linehan. Guilford Press; 2nd edition. I think it's a given that envy is associated with striving to have the thing or quality that someone has that you don't. However, it is very possible to admire someone and not want to seek out these admired qualities or abilities for yourself. Whilst envy often seeks to grab and rush and chase and push, admiration does not need to do these things. Admiration can be from afar because it's possible to admire and not want to possess. I can admire people in documentaries who climb Mount Everest and yet no part of me wants to reach the peak myself. I think the soft glow of admiration can quickly slip into more painful pangs of envy, especially when sadness or fear is involved. Take, for example, admiring a colleague at work for her ability to manage tricky conversations. If I start to compare my own ability to be tactful in a harsh and self-critical way ('I am so bad at handling tricky conversations compared to her'), then this can cause fear ('what if I lose my job?' 'I am so rubbish' ) which can then cause envy: 'I need to be as good as her at holding difficult conversations and I need to improve myself fast'. For people with BPD, I know how thought about not being good enough can suddenly morph into thoughts about self-harm or suicide. I wonder if admiration can be a pathway to feelings of inadequacy and even worthlessness for people with BPD, a trauma history or other emotional difficulties. Isn't it telling that I (and I suspect many others) are full of admiration for others, but don't stop to think about whether others may admire us? So what is helping me when admiring thoughts turn into thoughts about of incompetence or defectiveness? The remedy for me lies in becoming more trusting of myself and my abilities and more comfortable in who I am and in my skillset. It's not easy. It's not something that happens overnight. It's something that for me is very much a work in progress. What does that work look like? Well, each time I let myself rest when I am tired, I am telling myself that I am worthy of care and that I am good enough as I am in the place I am right now. Every time I feed myself when I'm hungry, I am giving myself the same message (I had an eating disorder when I was younger). Each moment I act in line with my values, say no or stand up for my wellbeing, I am affirming to myself that my way of doing things is okay; I don't have to be the same as everyone else. I have my own needs. I am my own person. Other people don't own me. Just before I wrap up this post, I just want to say that I would never want to remove envy from my life. I would never eradicate an emotion, no matter how painful, because emotions are natural and they have important functions. Envy has shown me what I want most in life; whilst painful, it has made me turn corners instead of continuing ahead. I enjoy admiration because it can brings warm and even soaring feelings of wonder, awe and respect. However, I want to make sure that admiration stays joyful and curious for me, rather than being one of my gateways to self-loathing and self-punishment. I want admiration to be something that inspires me to learn and develop, not a stick I beat myself with.

I am so excited to see people looking forward to reading my book, 'Talking About BPD A Stigma-Free Guide to Living a Calmer, Happier Life with Borderline Personality Disorder'. It's so great to hear so many of you pre-ordering too. Thank you, it feels really heartwarming. I have to admit, I have worked really hard on this book. It has taken many hundreds of hours or writing, researching and editing. I poured my heart into it because I wanted to make something truly comforting, reassuring and, ultimately, helpful for people with BPD. I remember how alone and scared I felt when I was newly-diagnosed...and how I needed a book that made me feel seen, validated and understood. I want people with BPD to be able to read something about their diagnosis and think 'ah, that makes sense now', rather than 'oh am I really a terrible attention-seeking monster with no hope for the future.' Some books I have read made me feel like the latter and it was so painful, not to mention detrimental to my mood and sense of self. So what's actually inside the book? Well, the book combines my personal experience of borderline personality disorder (including the events that led up to my diagnosis, the challenge of being diagnosed and how I felt to finally get this diagnosis). I share my difficulties in detail and how I came to a greater understanding of myself, my emotions, my thoughts and feelings. My book is intended as a gentle guide to BPD by a person with lived-experience (me!). It combines an in-depth look into one person's life with this condition (my life!) and then shares some coping techniques that can be helpful. It's neither medical manual, nor psychology handbook. Furthermore, it's certainly not any sort of 'quick fix wonder' book that claims to change your life in ten days. The book has been peer-reviewed by a mental health nursing senior lecturer and colleagues, as well as fully edited by my publisher, Jessica Kingsley. I am happy to say that my book is quite different to the vast majority of books about BPD on the market. For one, it doesn't talk down people with BPD belittle them or write them off as monsters. Secondly, the language is fairly accessible because it's written for a general readership rather than doctors or psychologists. So what will be covered in the chapters? Well, expect to find chapters on what BPD is, how it's diagnosed, treatments, dealing with stigma, coping with self-harm and feeling suicidal, relationships, coping techniques (largely DBT based) and more. I really hope you enjoy it when it's out on 21st October 2021. It's available to pre-order from many bookshops now.

I had a great time chatting with 'Needs More Nuance' during their monthly show at Netil Radio back in February. I spoke with Maciek from the show about relating to this diagnosis, the challenges of accessing help, mental health services in general and COVID-19. I wasn't as articulate as I wanted to be because I couldn't remember the word 'misogynistic' when I needed to use it (I was a bit tired!). Hope you enjoy the show if you choose to listen and please let me know your thoughts or questions if you have any. If you're interested in locating some of the studies I mentioned during the interview, or reading more about some of the topics discussed, I recommend checking out these links below: Bachmann, C. and Gooch, B. (2018) LGBT in Britain – Health. Stonewall. Available at: www.stonewall.org.uk/lgbt-britain-health Watts, J. (2016) ‘Borderline Personality Disorder – A diagnosis of invalidation.’ Huffington Post Blog, 26 September. Available at: www.huffingtonpost.co.uk/dr-jay-watts/borderline-personality-di_b_12167212.html Watts, J. (2018) ‘How can we expect borderline personality disorder patients to trust mental health services when the staff don’t trust them?’ The Independent, 21 July. Available at: www.independent.co.uk/voices/borderline-personality-disorder-mental-health-depression-anxiety-stress-psychiatry-a8456301.html Woollaston, K. and Hixenbaugh, P. (2008) ‘“Destructive whirlwind”: Nurses’ perceptions of patients diagnosed with borderline personality disorder.’ Journal of Psychiatric and Mental Health Nursing 15, 9, 703–709. Thank you Needs More Nuance and Netil Radio for having me on the show!

Pre-orders have now opened for my book, Talking About BPD: A Stigma-Free Guide to Living a Calmer, Happier Life with Borderline Personality Disorder, featuring a foreword by Kimberley Wilson. My book addresses what BPD is, how it is diagnosed and available treatments. It shares my personal experiences of living with this condition and advice for day-to-day life with BPD. In this book, I share lots of practical tips and DBT-based techniques for coping with intense emotions and difficult moments. Pre-order here Topics such as how to talk about BPD to those around you, managing relationships and self-harm are also explored. This book works to dispel stigma and challenge the stereotypes often associated with this condition. My book is a hopeful guide that offers support, understanding and validation for people living with BPD, as well as those who support them. I wrote this book for people who feel scared, hopeless, confused or alone with their BPD. I really hope you enjoy this book when it's out on 21.10.21. Would love to hear your thoughts about it later on this year. - Rosie

You're not 'too much'. You're not 'too emotional'. You're not 'too sensitive'. You're not 'too difficult'. You're not 'unlovable'. It took me a long time to believe it and even now, from time to time, I still have moments when panic rises and I feel like nobody in the world could love me. I take a breath and ground myself in my immediate surroundings. Then, I remind myself that I have been through a lot in life (some of it traumatic) which makes me feel 'too much' and 'unlovable' sometimes. I tell myself this is not true. Before I met my partner, I thought nobody could ever love me for who I am. I feared that my BPD-- with all my panic attacks, crying, anxious thoughts, therapy sessions and psychiatrist appointments-- would make me unattractive to any potential partners. Worse than that, I feared it would disgust, frighten or embarrass them. I also didn't know how I would cope with that happening. Part of me thought I needed to wait and start dating when my BPD was 'better'. But I didn't know when 'better' would come, or if it would ever come. The other part of me knew that I shouldn't have to deprive myself of a chance at love (something I wanted!) because I had mental health problems. Typical me, never one to sit back and wait, I decided to go for it. Maybe deep down, in my heart of hearts, I knew that people with mental health problems deserve and need love just like anyone without mental health problems. Perhaps, in spite of all my fears, I knew that I could love and be loved, irregardless of BPD. I set out dating with some strict rules. I promised myself that if anyone disrespected me, spoke down to me or showed any signs that they might be anything less than fully respectful towards people with mental health problems, then I would run. I gave no second chances because, after everything I had been through, I couldn't take the risk of being hurt again. After a little while and a few tears, I met my now partner. We both knew from the first date that we liked each other a lot. We were drawn to each other, enjoyed each others' company too much to be apart for long and fell in love pretty quick. It was easy, it was fun, it felt natural. It was love and it felt right to us. It still is and still does. I decided to tell him about my BPD quite soon after we met because I felt there was less chance of getting my heart broken early on if he reacted badly. He didn't. I cried. They were tears of relief. We hugged. He changed his t-shirt because of my tears. We laughed. We had pizza. Of course, sometimes there are things my partner finds hard about my BPD. He finds it hard sometimes when I am sad and he wants to take away my pain, but he can't. We think it is natural to feel sad when someone we love is upset. It's part of loving someone. It helps that we both have the understanding of emotional intensity and emotional dysregulation. We have found our own strategies to make it work when I'm especially anxious. We are open with each other and this works for us. We have a lot of humour in our life, we laugh a lot, and that levity helps. I spent years worrying I was too sensitive, but my partner loves me because of my sensitivity. He likes the fact that it is easy for me to feel excitement, joy, love and wonder. It makes life fun. Every day I am grateful that I went on the date and met him. I was so anxious that I wanted to cancel, but thank goodness I didn't. I gave myself a chance at love and it paid off for the both of us. I think the love we have together has been, and still is, incredibly healing for me. I wish that nobody had to feel unlovable because it's not true. I know that lots of people diagnosed with BPD have been in situations that made them feel like there was something wrong with them or bad about them. Situations like these can take the hope out of a person and make them feel worthless. Recognising that the way we feel about ourselves often relates to things that happened to us can be a first step to glimpsing a different perspective on who you are. Love is possible with BPD. I hope reading a little of my story is helpful. My book Talking About BPD: A Stigma-Free Guide to a Calmer, Happier Life with Borderline Personality Disorder is out 21.10.21 and published by JKP. Sign up for pre-order alerts on my homepage! If you enjoyed this post, please consider helping me with my running costs by donating on Ko-Fi. Your support is much appreciated as it helps me pay for my website and associated running costs.

*Please note that this post references trauma, including a brief mention of sexual assault, so please take care.* Lately, I've been seeing a lot online about the need for trauma informed mental health services, but it's not just mental health care that should be trauma informed— I believe physical health care should be too. Now before I get into the nitty gritty of this post, I will say that this post is not to debate what 'trauma informed' means and whether it's being properly used by organisations in a meaningful way or not. Rather— for the purposes of this post— what I mean by trauma informed is having an understanding of what trauma is, how it affects individuals and what can be done to reduce suffering and avoid re-traumatisation. As you may well know, the link between borderline personality disorder (BPD) and experience of trauma is well-documented. A study from the University of Manchester showed that 'people with BPD are thirteen times more likely to report childhood trauma than people without any mental health problems'. That's not to say every person with BPD has, or identifies with having, a trauma history though. It's important to know that a proportion of people with this condition don't identify with having experienced trauma. Dr Filippo Varese from the University of Manchester notes that this study's findings 'underline the importance of trauma-informed care for people accessing mental health services, where prevalence rates of BPD are high.' I couldn't agree more. It goes without saying that the better mental health professionals understand the impact of trauma on emotion regulation, cognition and sense of self— and who then respond appropriately— the safer individuals with BPD and/or a trauma history will be during clinical encounters. I think I speak for lots of people with BPD and not just myself when I say that physical, as well as mental, health services, need to be trauma informed. I believe that physical healthcare practitioners need at least a minimal working knowledge of trauma and its potential impacts on both the mind and the body (as connected as they are). And I don't mean doctors and nurses only, but the full range of medical and healthcare professionals— from paramedics to pharmacists, midwives, podiatrists, dentists, physiotherapists and dieticians, to name just a few of the many physical health clinicians. An encounter with a healthcare professional, regardless of whether the patient is there for something psychological, physical (or a mixture of the two) is often deeply personal. After all, health professionals are privy to knowledge that even people in their patients' personal lives might not be. Pharmacists, psychotherapists, midwives, GPs, physiotherapists and dentists may see and know things about our bodies and minds that people outside of that clinical room might never know. Maybe it's that such information is just not relevant to share with people we know interpersonally, or maybe we just don't want others to know or find it too difficult (or embarrassing?) to share. There is a certain physical intimacy to healthcare and I hope professionals never, ever forget the intense anxiety this can provoke. A professional may look at, even into, parts of our bodies that few (or no) others have ever been privy too. Not only might they look, but they might also listen, feel, prod, open, slice, cut or inject. We can experience feelings of vulnerability, exposure, loss of control and— depending on whether we have had, or continue to have, negative messages about our bodies and self— embarrassed, humiliated or threatened. Of course, given the right clinician and environment, the hope is we can feel a whole spectrum of more positive feelings too such as supported, comforted, reassured and even restored. There are all sorts of complex reasons why accessing healthcare can be anxiety provoking, from fears of exposure, invasion of personal space and a reminder that the body and the mind are imperfect and subject to change. Whilst our bodies and minds have incredible capacities to heal and modern medicine has technologies akin to magic, going to an appointment can be a reminder that the human body has it's limits and frailties. And acknowledging that whilst most problems have solutions, some may only be partial and, more rarely, some may have none at all. Sometimes the social implications of a health problem can be more painful than the physical issue itself. As medical historians have noted, since the dawn of time ill health has been associated with stigma. As the sociologist Erving Goffman described it, stigma refers to the 'situation of the individual who is disqualified from full social acceptance'. To be stigmatised is to experience, on some level, a rejection. The stigmatisation of illness is culturally and temporally contingent (it depends on where a person is in time and place). Notable examples of illnesses that have been, or still are, particularly stigmatised include include HIV, sexually transmitted infections, cancer, illnesses that affect reproduction or excretion, and, of course, mental illnesses. Unfortunately, some illnesses have been— or still are— incorrectly associated with being dirty, immoral, lazy or even less lovable. Some examples include 'if I have HIV, will I still be attractive to my partner?', 'Does my diabetes mean I did something bad?', 'If my employer knows I have bipolar, will I lose my job?', ''Is it embarrassing that I had a knee replacement?'. It is notable that one of the most common fears is fear of the dentist and for many people this is linked to fear of being seen in a negative manner (or even scolded) by the dentist. For people with BPD and/or a trauma history though, feelings of vulnerability, exposure and powerlessness may feel especially strong and overwhelming. People who struggle with emotion regulation or who dissociate or experience flashbacks may find a clinical encounter completely overwhelming. It might look like 'zoning out' during a physical examination with the physio, crying whilst having a check up at the dentist, breathing very fast and feeling panicky when getting your eyes tested or struggling to find the words to speak to a GP. If a person is not able to soothe intense emotions or manage difficult thoughts and the clinician is not aware of able to support, then an appointment may become really difficult. In some instances, medical examinations or procedures might remind people on some level of past traumatic experiences. That 'small thing' that frightened the young child that seemed like 'normal' at the time, but became a terrifying memory; and now the adult 'becomes' that frightened child every time they are back in similar situations. Maternity care is a key area that requires trauma informed thinking, especially for those who have experienced sexual abuse and/or assualt. The My Body Back Maternity Clinic is the first maternity clinic in the world specialising in post- and antenatal care for people who have been sexually assaulted and I hope more clinics do work of this type in the future. Shame is all too often the elephant in the clinic room and I think especially so for people with BPD and/or a history of trauma. As several studies describe, both shame and guilt, the 'so-called self-conscious emotions, are of central clinical relevance to BPD' (Gratz et al, 2010,). A 2009 study found that participants with BPD had both 'higher levels of shame in response to the negative evaluation' and levels that took longer to dissipate than participants without BPD (Göttlich et al, 2009). Put simply, shame is an emotion that can arise in interpersonal encounters. It can be felt when a person feels or is told, either directly or indirectly, that something about them is wrong, bad or unworthy. It's associated with a negative evaluation of the self (feeling bad about who you are) and it is often accompanied by an urge to hide the aspect that feels bad or wrong. How many people go to a doctor / physio /dentist / other professional and reveal things they were too scared to share with anyone else? Sadly, illness tends to be (either implicitly or explicitly) associated with being flawed, dirty, weak or bad: 'there is something wrong with your eye / heart / leg / uterus / teeth.' People live in their bodies; their sense of self is tangled up with their physical being. Illness is by it's very nature deeply personal. It therefore makes sense that some people feel great shame during medical encounters. I wish this weren't the case. For better or for worse, clinic rooms can feel like confessional spaces for some people. 'I'm worried about ____ and I haven't told anyone' or 'I've been in pain for years with ____, but I was too scared to do anything about'. When a clinician skilfully tends to the patient's experience of shame, then their 'uncovering' is liberating. (The etymology of the word 'shame' is said to mean 'uncovering' which seems very apt for medicine.) In other instances, the clinician fans the flames of a patients' shame and they leave feeling more isolated and more unworthy than ever. A classic example would be someone who went to the dentist after avoiding appointments due to anxiety, felt humiliated and then felt too upset to go back. Luckily this becoming more rare as more professionals are understanding their responsibility to be empathetic and compassionate. I think Brene Brown is more or less spot on when she says 'shame cannot survive with empathy'. Although dissolving deeply rooted shame may require repeated doses of instances of empathy over time. I guess that's how trust is built too. In 'Humanising Birth: Does the Language we Use Matter?', N. Mobbs, C. Williams and A. Weeks write that it is the 'duty of caregivers to use language that will help empower all women'. 'Language signals the nature of the relationship between woman and caregiver, and can deny or respect a woman’s autonomy.' The authors of this paper describe that words like 'failure to progress', 'failed induction' and 'poor maternal effort' unfairly judge and blame a person giving birth. An NHS document about language and diabetes urges clinicians to 'be aware of the impact [our] words may have on their diabetes care'. It explores 'compliance', 'being told off', and the semantics of cheating and goodness/badness. The document begins 'with great power....'. With that 'great power' should come that 'great responsibility' of considering how language can either hurt or heal. In 'The Value and Benefit of Narrative Medicine for Psychiatric Practice', my friend Dr Sabina Dosani, Child and Adolescent Psychiatrist, explains the merits of paying close attention to the metaphors and stories that patients use to express their inner lives. She explains the fruitfulness of applying 'close reading skills from literary studies' in her work. Dr Dosani explains that paying attention to story and showing sensitivity towards language enables her to connect with, and better understand, the families and children with whom she works. Given that shame is a social emotion, interpersonal communication is nearly everything when it comes to breaking it down, but environment can play a part too. Shame is a self-conscious emotion often associated with feeling stared at or exposed and clinic rooms are usually full of bright lights, mirrors and requests to remove clothes, lie underneath surgical lights and encounters with equipment that literally looks— or even goes—into our bodies. What can be done with a simple knock on the door, adjustment of the light, curtain or the words 'are you ready?' to help a patient feel less invaded, watched or to give a little more privacy? I have been carrying shame from a medical encounter many years ago. If this professional had thought about how judgmental they were coming across, how helpless they made a child feel and the impact of such negative language on a young mind, then how much suffering would have been avoided? If the clinician had paused to reflect on how their big heavy body compared to my small powerless one, how their certificates on the wall felt in the context of my vulnerability, then maybe they would have thought twice about their responsibility. Whilst time has passed and I tell myself I never deserved that, my body reacts by tensing muscles, racing heart, sweating and vivid images in my mind's eye. Luckily, I find avoiding my fears more uncomfortable than facing them and no matter how terrified I am of re-experiencing shame, I always show up to appointments. I'm grateful to have had some healing experiences in adulthood. These empathetic encounters have given me the chance to realise I didn't deserve that humiliation. I'm hopeful that health professionals are becoming increasingly reflective about how vulnerable a patient may feel and thinking about communication and environment. I would never expect 'perfection' (whatever that is!), I only ask that a professional is thoughtful about how they communicate and what they do. Can you relate to my emotions in this post in any way? I would love to know your thoughts on what I've written, whether you are a clinician or a patient who has experienced shame and/or with BPD and/or a trauma history. I would like to thank my friend Dr Sabina Dosani for chatting with me about these issues and giving me some of the ideas in this post. References: Erving Goffman, Stigma: Notes on the Management of Spoiled Identity (London,1963). Farnam Street, Brene Brown: The Difference Between Guilt and Shame' (undated). Sabina Dosani, 'The Value and Benefit of Narrative Medicine for Psychiatric Practice' (BJ Psych Bulletin, 2020) Natalie Mobbs, Catherine Williams and Andrew D Weeks. 'Humanising birth: Does the language we use matter?' (The BMJ Opinion, 2018). NHS England, 'Language Matters: Language and Diabetes', 2018. University of Manchester 'Borderline Personality Disorder has strongest link to childhood trauma' (https://www.manchester.ac.uk/discover/news/borderline-personality-disorder-has-strongest-link-to-childhood-trauma/) Martin Göttlich, Anna Lisa Westermair, Frederike Beyer et al 'Neural Basis of Shame and Guilt Experience in Women with Borderline Personality Disorder (European Archives of Psychiatry and Clinical Neuroscience, 2020) Kim L Gratz, M Zachary Rosenthal, Matthew T Tull et al, 'An experimental investigation of emotional reactivity and delayed emotional recovery in borderline personality disorder: the role of shame' (Comprehensive Psychiatry, 2010).

*Please take care with this article as it discusses hate crime and discrimination against LGBT+ people, as well as suicide statistics.* Whilst researching and writing my book, I examined numerous studies on stigma and borderline personality disorder within healthcare and, more specifically, mental health services. I also looked at research on the experiences of LGBTQ+ people within mental health services. However, when it came to finding specific studies on the experiences of stigma within mental health services for LGBTQ+ people diagnosed with BPD, I couldn’t find anything. It appears to me that nobody has researched LGBTQ+ people with a diagnosis of BPD and their experience of mental health care. I am going to share some general statistics from a couple of Stonewall’s reports about life in Britain for LGBT people, followed by some statistics about the experiences of people with BPD as a whole. After I share these statistics, I will speculate on what they could possibly say about the experiences of stigma within healthcare for LGBTQ+ people diagnosed with BPD. I am no statistician or population researcher, however I can’t help but wonder what these two areas of research might be able to say about the experiences of LGBT+ people diagnosed with BPD and their interactions with the services and professionals that are supposed to be helping them. I hope one day soon some studies will be done in this area and I won’t have to conjecture like this. I also want to preface my thoughts by saying I have no doubts there are some excellent clinicians who are fully respectful towards LGBTQ+ people and do a lot to ensure that everyone is treated equally and with an understanding of the additional challenges they may, at times, face in society. Let me begin with Stone Wall’s 2017 report ‘LGBT in Britain - Hate Crime and Discrimination’. This report paints a picture of how dire the situation is for LGBT people in the UK right now. Even daily life is, or feels unsafe, for a huge proportion of LGBT people, especially those who are BAME. A third of black, Asian and minority ethnic LGBT people have experienced a hate crime or incident based on their sexual orientation and/or gender identity in the last year compared to one in five white LGBT people. Two in five trans people have experienced a hate crime or incident because of their gender identity in the last 12 months More than a third of LGBT people (36 per cent) say they don’t feel comfortable walking down the street while holding their partner's hand. This increases to three in five gay men (58 per cent). Stonewall, 2017. This report also reveals what many already know- that health and social care services aren’t psychologically safe, or fit for purpose, for LGBTQ+ people. Again, BAME LGBTQ+ people are more likely to be discriminated against than white LGBTQ+ people. One in eight LGBT accessing social services in the last year has been discriminated against because of their sexual orientation and/or gender identity. The rate of discrimination is even higher in this area for trans people. A quarter of trans people who contacted emergency services in the last year were discriminated against based on their gender identity. One in six black Asian and minority ethnic LGBT people were discriminated against by emergency services compared to five percent of white LGBT people. Stonewall, 2017. This report provides a snapshot into the reality of just how uncomfortable and/or unsafe life can be for LGBT people, particularly BAME LGBT people. As this report points out too, hate crimes are underreported due to fear of not being believed or being blamed by police or other institutions that hold power. Let’s now look at Stonewall’s 2018 report on Health and LGBT people in Britain. Here are some statistics on the mental health of LGBT people: Half of LGBT people experienced depression in the last year. Two thirds of trans people have experienced depression in the last year. 13 percent of LGBT people aged 18-24 (13 per cent) said they’ve attempted to take their own life in the last year. The rate is significantly higher for trans people. Stonewall, 2018 LGBTQ+ people are far from guaranteed respect and empathetic care when they access health services: Almost one in four LGBT people have witnessed discriminatory or negative remarks against LGBT people by healthcare staff. This figure rises to 20 percent of trans people. One in twenty LGBT people (five per cent) have been pressured to access services to question or change their sexual orientation when accessing healthcare services. One in seven LGBT people avoid seeking healthcare for fear of discrimination from staff. I am not saying that the above statistics mean that every LGBTQ+ person is at risk of having a negative experience when they access medical care. I am just saying that healthcare systems need to be made much, much safer for LGBTQ+ people. We need to get to a place where there is very minimal risk of being insulted, disrespected, judged, harmed or made to feel uncomfortable in a healthcare setting. LGBTQ+ people have every right to be as safe, as respected, as cared for as people who are not LGBTQ+. More needs to be done to ensure this. Let me now turn to some statistics on the stigmatisation and discrimination of individuals diagnosed with BPD: One study found that inpatient mental health nurses were more likely to ‘belittle’ patients with BPD than those with schizophrenia (Gallop, Lancee and Garfinkel 1989). Whilst mulling over this statistics, it is worthwhile bearing in mind that schizophrenia is one of the most stigmatised mental health conditions. A 2007 study found that mental health nurses were more helpful to patients with major depressive disorder than those with BPD (Forsyth 2007). Another study showed that patients with diagnosis of BPD were judged more negatively by staff than patients with other diagnoses (such as schizophrenia) even when their behaviour was the same (Koekkoek, Berno Van Meijel and Hutschemaekers, 2006). A 2017 study showed that in England, 84% of organisations (English NHS mental health trusts and independent organisations) reported having at least one dedicated personality disorder service. However, only 55% of organisations reported that patients could access these dedicated services equally across localities (Dale, Sethi and Stanton, 2017). The gaps are still there in service provision for people with BPD; many are not being offered the support they need. It is not uncommon for people to be on waiting lists of a year or more for psychological treatments. So, what might all of this mean LGBTQ+ people with a diagnosis of BPD? I want to hazard a guess that discrimination on the basis of gender identity and/or sexual orientation affects LGBTQ+ people with BPD at the same or higher frequency than LGBTQ+ people who don’t have a BPD diagnosis or people with a BPD diagnosis who are not LGBTQ+. I would love to hear from you if you are LGBTQ+ and have a diagnosis of BPD (or relate to this diagnosis, even if you haven't been formally diagnosed). If you would like to share, what are your experiences? Have you faced inequalities? Have you been discriminated against, treated unfairly or stigmatised? Do you think you have a harder time within mental healthcare services being LGBTQ+ and having BPD compared to someone with this condition who is not LGBTQ+? If you would like to write a blog post about this or share something of your experience on this blog, then please email me at rosie@talkingaboutbpd.co.uk. Anonymity is fine if that is needed or preferred. Information and support is available from Stonewall's Information Service. Their freephone number is 0800 0502020. References: 'LGBT in Britain - Hate Crime and Discrimination' report by Stonewall, 2017. LGBT in Britain - Health report by Stonewall, 2018. Further reading- an article I found that may be of interest: ‘Distinguishing and Addressing Gender Minority Stress and Borderline Personality Symptoms’, H. Goldhammer, C. Crall and A. Keuroghlian. Harvard Review of Psychiatry, 2019.

I've written a book for people with a diagnosis of BPD, or people who identify with this diagnosis! It's out 21st October 2021. ​ It combines practical advice and coping tips with my personal experience. I wrote it because I know how hard it can be to live with such a stigmatised and misunderstood mental health condition. The book contains advice on topics such as dealing with stigma, long waiting lists, stereotypes, painful emotions and talking about the condition. ​It features a foreword by a leader in the mental health field, Kimberley Wilson and has been fully peer-reviewed. The book will be published by Jessica Kingsley Publishers. ​ If you would like to receive a pre-order link once it's available, please sign up to an alert on my homepage. Can't wait to share to share the book with you!