‘I don’t see EUPD; I see you and your situation’

"There is no point, I have Emotionally Unstable Personality Disorder and it can't be cured" 
"I was given an EUPD diagnosis, and I don't know what it means"
"I don't feel like I have a personality disorder. I think I am traumatised"
"It makes me feel like something is wrong with me."

These are some comments I have heard from patients while working in mental health care since 2022, first as a support worker, then as an Assistant Psychologist. Such statements are frustrating for me because the patient speaks as if they are inherently flawed or that they have a disease. They remind me that mental health services can sometimes unintentionally harm a person; for the patient, these misunderstandings challenge their hope for change.

EUPD is not a disease; it is a way to describe certain psychological difficulties, and it's not unchangeable (Doolan & Bryant, 2012; Smits et al., 2022). It's time for greater understanding of what EUPD is and, more importantly, what it isn't.

The problem with misunderstanding

I believe that, as a priority, mental health teams need to address the misunderstandings that can arise from an EUPD diagnosis. Patients deserve to feel hope and validation, not despair and alienation, especially if such feelings are based on false assumptions. People come to mental health services to try to make sense of their experiences, reconnect with themselves and society, and heal from traumas. A significant proportion of people with an EUPD diagnosis have suffered from difficult upbringings or early life traumas (Cattane et al., 2017)

This isn't a crusade to eliminate EUPD as a diagnosis. Some patients find diagnoses helpful as they provide a reference point for their distress. However, even in these cases, people should be clear about what a diagnosis means and what it does not. 

So, what exactly Is EUPD?

Emotionally Unstable Personality Disorder is a term used to describe emotional instability, difficulties with self-identity, and challenges in relationships (American Psychiatric Association, 2013). It is not a disease caused solely by biological factors (Hyman, 2020). Psychiatry acknowledges that mental health issues cannot solely be explained by biology (Choudury & Slaby, 2012). It is generally accepted that the psychological patterns defined as EUPD often result from growing up in difficult environments. Yet I find patients are not aware of this context.

Instead, they respond to their diagnosis as if they have an underlying disease or that they are at fault. Such confusion likely affects many psychiatric diagnoses, but EUPD is particularly harmful because it involves judgments about a person's character and can reduce their sense of agency. The language used in the diagnosis suggests something fundamental about the person, but research shows the difficulties described by EUPD can be changed (Doolan & Bryant, 2012; Smits et al., 2022).

Patients in my experience are not informed of this enough, leading to statements that show an unnecessary internalisation of harmful and incorrect information. This isn't fair, and I believe we should remind ourselves and our patients that EUPD is a description of current challenges, not an unchangeable part of who they are. In my experience, when this is communicated to patients, they can feel a great sense of relief and validation, realising they do not have an incurable condition.

Forming a shared understanding

As an Assistant Psychologist, I work to help patients understand their mental health through education, forming a shared understanding – called a formulation – and via psychological interventions (Johnstone & Dallos, 2013). A key role in psychology is to educate and empower patients to understand their mental health, according to psychological theory. My view is that we also have a role to educate patients on mental health more generally.

Given this, I have taken time to communicate with patients that they don't 'have' EUPD in the way one might have a physical illness. Rather, their difficulties, which might include emotional instability, issues with self-identity, self-harm, and relationship problems, are described as EUPD by some professionals. Specifically, EUPD doesn't cause these issues; instead, these challenges are grouped together under the term EUPD (Hyman, 2020). 

I understand that sessions are for patients to understand themselves, not for me to impose my views. Therefore, I only take such an approach where patients are confused. A diagnosis can be validating for some patients, and I don't want to undermine that. Still, I believe patients should have access to information that might change how they see themselves.

So, when a patient says to me, 'I can't get better because I have EUPD,' I remind them, 'You don't possess EUPD; EUPD is a term used by some professionals to describe your experiences,' or 'I don't see EUPD; I see you and your situation. Let's revisit our understanding and think about why you might be feeling this way and what might help you improve.' Several patients have told me that this understanding is soothing and validating, as they were either confused by their diagnosis or thought they were dealing with an incurable disease.

Encouraging change

I believe mental health teams should engage in efforts to ensure patients receive information to help them understand their diagnosis. I encourage others to contribute to broader discussions and efforts to help systems to stop reinforcing harmful misconceptions, especially in the case of EUPD.

I also urge psychologists and aspiring psychologists to familiarise themselves with the philosophy and scientific background of diagnoses. This knowledge helps us avoid the same pitfalls that patients experience, such as treating diagnoses as unchangeable diseases. Most importantly, it allows us to help patients see that they have the potential to change and improve.