“She’s just borderline”: The systematic denial of trauma in Australia’s health care system

Imagine being so distressed, hating yourself so much that you literally harm your own body, and after summoning whatever reserves of courage you have remaining you arrive at emergency. You sit under phosphorescents and itch with anxiety until they call your name. Only to sit down on a bed and be spoken to like a naughty child. A professional person in scrubs looks you in the eye and says: “You don’t need anaesthetic for your stitches because you like pain, don’t you.”

This is the reality for many of my clients with complex trauma and by no means the most extreme outcome of seeking care for their symptoms. Over the past twelve (12) years I have primarily worked with complex trauma, that is, clients who have experienced a pattern of prolonged and repetitive abuse and neglect from childhood onwards. Many individuals with complex trauma present with a range of symptoms that are deeply stigmatised. Significant self-harm, high risk behaviours, significant suicide attempts and other self-destructive behaviours such as self starvation. These clients are also likely to struggle with dissociative disorders, psychosis, and a general mistrust of others, including health professionals. This type of presentation results in tremendous challenges accepting care.

While these behaviours are significant and in some cases can be lethal, they are merely the tip of the iceberg.

The self-harm, the drug use, the impulsivity etc, are not the problem. They are the response to the problem.

These individuals are people who carry unimaginable stories of abuse and neglect. Their pain is unbearable to them, and so they cope the only way they know how.

Over the decade I have dedicated to this space, I have noticed a distinct pattern in the way clients with this presentation are treated in the Australian healthcare system. Individuals with this presentation are not viewed as people with legitimate pain resulting from complex trauma, but are instead slapped with a personality disorder. More specifically, Borderline Personality Disorder. Or even more pejoratively, simply “borderline.”

Borderline Personality Disorder (BPD) is a diagnosis entrenched in stigmatisation and dismissal, akin to Freud’s hysteria, a diagnosis also disproportionately given to women. There is a current debate over whether to keep BPD in the Diagnostic Statistical Manual (DSM) or to drop BPD from the manual. One side argues that BPD is a sexist label used to pathologise women with deep distress - particularly those who have experienced trauma and/or are neurodivergent. The other side argue that despite the problematic connotations, when used respectfully, emphasising the chronic emptiness and attachment trauma, BPD can be validating for individuals who identify with the symptoms list.

Regardless of where you sit on the BPD debate, the way BPD is used in the Australian public health care system is purely pejorative: condescending and disrespectful does not approach the daily experience of individuals that receive this diagnosis in public hospitals. These individuals are diagnosed because they have presented with significant self-harm. Behaviours, again, that manifest as acts of self-harm to simply cope. To deal with the horrors inflicted on them, often by those closest and those supposed to care and protect. In my experience, when a BPD diagnosis is given in the public system, it is done, astoundingly, without a diagnostic interview. Without a history being taken. Without consulting the individual's treatment team. Without assessing and ruling out alternative diagnoses or explanations. Without considering the potential harm from such a label.

On more than one occasion clients have reported being diagnosed without even meeting the psychiatrist providing the diagnosis. The psychiatric care team read on file the reason for the person presenting to hospital, diagnose them as “Borderline Personality Disorder” and discharge them. This “method” of diagnosis is not diagnosis. It is at best inaccurate, and at worst negligent. It is lazy healthcare.

Let me interpret this common use of BPD for you: the meaning behind this passive approach. A diagnosis of BPD in this context says “this problem is behavioural attention-seeking, and therefore care only reinforces the problem.”

But don’t worry, we can always recommend Dialectical Behaviour Therapy (DBT). These clients are always recommended DBT. Always.

DBT is a great option for many individuals, but it is not an automatic “fix” for all these presentations - DBT is focused on symptom management and does not address underlying trauma. More recently, DBT has been criticised by the lived experience community for reframing trauma response/survival strategies as behavioural problems. And being a group therapy by definition precludes DBT as treatment for many individuals, especially many neurodivergent individuals or those with traumas that mirror a group environment too closely. The hospital staff also frequently neglect to explain that the waitlist for publicly funded DBT program tends to be at least twelve (12) months.

At the bottom of this article I have included an excerpt taken from a clients Acute Management Plan (written by their local public hospital). This client has severe and chronic trauma, but the management plan posits the primary diagnosis as BPD - and therefore the key issue behavioural and a transactional skills deficit (aka poor relationship skills) and therefore the only appropriate intervention being skills training. Imagine being systematically assaulted, abused, and neglected throughout your life only to have a team of medical professionals conclude that the primary issue is a personalty disorder resulting in poor relationship skills and the treatment being to learn more coping skills. No acknowledgment of trauma or of the suffering experienced.

The most disturbing element here is not the BPD diagnosis itself, but rather what my clients report happens to them once that label is given. Clients of mine labelled with BPD have self-reported the following experiences:

Being spoken to like a “naughty child” - their symptoms of self-destruction and harm treated as spilling food on the carpet. Having requests for pain management systematically ignored at every stage of treatment: being denied anaesthesia during suturing; and being denied anaesthesia for an endoscopy. Being denied potential life saving surgery.

That is if they are given any treatment at all. In my experience healthcare professionals have interpreted research showing that those with “BPD” do not benefit from long hospital admissions as a green light to deny treatment or admissions of any length for all individuals presenting with self-harm.

And if they have been admitted or are awaiting care, my clients report general neglect - being left in a bed forgotten about. Not being given fluids for extensive periods and “casual” monitoring. Being physically held down and restrained (not unlike their trauma experiences). Care plans that include a recommendation to provide a sedative the individual is allergic to, to get them “under control” and even care plans that have the familial parent, who is the individual's perpetrator, listed as the “support person.” Then refusing to remove that person from the plan when requested.

I anticipate that some reading this may see me believing my clients as “splitting” - the language used in the healthcare system for not adequately fact-checking stories presented by individuals with personality disorders and therefore colluding with their illness. But when it is client after client across over a decade of practice, I struggle to draw any other conclusion. I have had both clients and colleagues who have worked as nurses in local emergency departments describe the culture as “disgusting” and “toxic when it comes to mental health.” Not only do I have consistent reports from clients and colleagues, I have observed this punitive approach myself through the language used by hospital staff during peer consultations. The language and approach is not trauma informed, not neuroaffirming, and not intersectional. Instead the patient is spoken about as a scheming manipulator engaging in self destructive behaviours to (and I quote) “get attention” and “elicit care.” In recent correspondence from a psychiatrist, the client's coping strategies were described as “indulging heavily in self-destructive behaviours.” Yes you read that right - indulging.

On one occasion I’ve obscured for privacy, a hospital staff member requested to consult with me about a shared client, an extremely rare occurrence to begin with. The hospital staff in question wanted to know my take on why the client was routinely presenting with such extreme self-harm behaviours, and in some cases, violence towards others when under threat. After gaining the client’s consent I outlined the individual's trauma history. Explained the trauma-informed approach I have come to use with this client. How I manage to successfully de-escalate this client. And before I finished the staff member interrupted and said “yeah but don’t you agree that she’s just borderline?”

Let me put it bluntly. I do not care if someone has BPD. BPD should not be used as a justification for mistreatment or non-treatment. At present in the Australian healthcare system BPD is being weaponised to deny trauma and posit victims as the problem. BPD is too often used as a justification for lazy, neglectful, non-individualised, non-empowering health care, and in some cases, results in the denial of care completely.

In short, the Australian healthcare system is systematically failing patients with complex trauma through inappropriate diagnosis and harmful treatment practices. The key presenting issues can be summarised as follows.

1. Inappropriate Diagnostic Practices
- A BPD diagnosis made without diagnostic interviews or proper assessment  
- Diagnosis given without the psychiatrist meeting the patient  
- Complex trauma symptoms (in some cases also neurodivergence) being mislabeled as a personality disorder

2. Harmful Treatment Practices
- Denial of appropriate pain management and anesthesia
- Dismissive and infantilising treatment by healthcare staff
- Physical restraint mirroring trauma experiences - Inclusion of abusers in care plans
- Systematic denial of hospital admissions
- General neglect during care

3. Systemic Problems
- Over-reliance on DBT as a one-size-fits-all solution
- Long waitlists (12+ months) for public DBT programs
- Lack of intersectional, trauma-informed, or neuroaffirming care
- Perpetuation of power imbalances in healthcare relationships

Nothing About Me Without Me

“Nothing about me without me” involves including and platforming lived experience perspectives in treatment decisions.  This shift towards incorporating patient perspectives can lead to significantly improved care outcomes, particularly through three key avenues: empowering patients in their treatment decisions, valuing patient autonomy and expertise, and fostering collaborative care approaches.

While the recent adoption of "nothing about me without me" by Australian hospitals represents a promising step toward patient-centered care, the gap between institutional rhetoric and frontline reality remains stark. For my clients with complex trauma histories, this well-intentioned shift has yet to translate into meaningful changes in emergency room culture or treatment approaches. True implementation of this principle requires more than new policies, training, or mission statements - it demands a fundamental shift in how healthcare workers view and treat patients presenting with trauma symptoms. Until we see consistent evidence of trauma-informed care, proper diagnostic practices, and dignified treatment in our emergency departments, "nothing about me without me" risks remaining just another well-meaning slogan that fails to protect our most vulnerable patients.

Conclusion

The current use of BPD diagnosis in the Australian healthcare system often serves as a tool for discrimination and denial of care rather than a pathway to healing. A fundamental restructuring of how complex trauma is understood and treated is needed, with emphasis on intersectional, trauma-informed, neuroaffirming, patient-centered care that recognises and respects the dignity and autonomy of all patients.

Written by psychologist Lucy Smith.

Editing assistance from D.C. McNeill

Example of an Acute Management Plan (deidentified)

X has a primarily diagnosis of Borderline Personality Disorder. This is a disorder of biosocial transactional aetiology resulting in significant skills deficits regarding self-regulation, distress tolerance, interpersonal skills, and emotion regulation. As such there is no biological treatment (medications, ECT) that have any impact on the core BPD pathology except DBT, which focuses on skill development. Mental health admission therefore has no active treatment component.

Any admission to hospital should be minimised as this may further reinforce x's ineffective coping strategies thereby increasing the likelihood of repeating or intensifying her high-risk behaviours and self-injury and therefore increasing mortality. Admission also hinders the opportunity for x to engage with her professional supports and further develop DBT skills.

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A note from Lucy - I do agree that lengthy hospital admissions are not helpful in these circumstances. It is the language and the oversimplified diagnosis, conclusion, and treatment recommendation that I object to.

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