1

A Qualitative Approach to Evaluate the Stigma towards People

with Borderline Personality Disorder in the North West of

England

A postgraduate dissertation submitted to Liverpool Hope University in partial

fulfilment of the requirements for the degree of M.Sc. Psychology

Researcher: Sara Naderali - 20208619

Supervisor: Jane McGagh

April 2023

Word count: 8,830

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Access to the dissertation

This dissertation can be used by Liverpool Hope University (LHU) tutors to support

other students who are undertaking research.

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Executive Summary
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Contents

Glossary 6

Abbreviations 6

Introduction 8

Research Aims 8

Research Questions 9

Literature Review 9

Borderline Personality Disorder 9

Stigma and Mental Health 10

Stigma and BPD 11

Methodology 12

Philosophy 12

Strategy 13

Methods 14

Generalizability 15

Reliability 15

Limitations 16

Data Analysis 16

Ethics 17

Findings 17
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Study Participants 18

Results 19

Understanding Stigma 19

Bipolar Disorder 20

Anger 20

Emotional Instability 21

Trauma 22

Negative Perceptions 23

Education 25

Discussion and Conclusions 25

Discussion 26

Conclusion 28

Recommendations and Impact 28

Recommendations 28

Impact 30

Critical Reflection Statement 30

References 32

Appendices 43
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Glossary

Bipolar Disorder – A psychiatric disorder that is characterised by extreme mood swings

between depression and mania

Borderline Personality Disorder (also known as Emotionally Unstable Personality Disorder) –

A psychiatric disorder that affects one’s mood and interactions with other people

Dialectical behaviour therapy – A type of talking therapy specifically designed to support

people who experience intense emotions

Mania – A period of over-active and highly energised behaviour that has a significant impact

Non suicidal self-injure – self-harm with the intent of causing physical pain to oneself to self-

injure but not to end one’s life

Personality disorder – A group of psychiatric conditions where an individual’s thoughts,

feelings, and perceptions differ significantly from the average person, impacting their

behaviour

Psychiatric disorder – A mental illness that is diagnosed by a clinical mental health

professional

Abbreviations

BPD – Borderline Personality Disorder

DBT – Dialectical behaviour therapy

EUPD – Emotionally Unstable Personality Disorder

GDPR – General Data Protection Regulation

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IPA – Interpretative phenomenological analysis

LHU – Liverpool Hope University

MSc – Master of Science

NHS – National Health Service

NSSI – Non suicidal self-injury

PD – Personality Disorder
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1.0 Introduction

Mental health awareness has substantially increased over the past decade with many more

discussions around mental health taking place, supporting society to become more aware of

mental wellbeing as well as leaning to accept mental illness in the same manner as the

physical illnesses (Arango et al., 2018; Cullen et al., 2020; Purcell et al., 2019; Sontag-Padilla

et al., 2019). This awareness has been further facilitated by the COVID-19 pandemic.

COVID-19 appears to have had a significant effect on people’s mental health, and with more

resources and services available for those who do need support with their mental wellbeing,

which has led to further improved societal awareness, which in turn has led to a rise in mental

health awareness (Arango et al., 2018; Cullen et al., 2020; Purcell et al., 2019; Sontag-Padilla

et al., 2019). However, stigma around mental illnesses still appears to be prevalent and is a

significant issue that affects millions of people around the world (Fox et al., 2018; Klein et

al., 2021). The consequences of mental health stigma can be severe. Stigma can prevent

people from seeking help for mental health conditions, leading to delayed or inadequate

treatment, poorer mental health outcomes, and increased risk of suicide. Stigma can also

impact relationships, employment opportunities, and overall quality of life, leading to social

isolation, reduced self-worth, and diminished well-being. It is a pervasive problem that can

have serious consequences for individuals with mental health conditions, including reduced

access to care, decreased quality of life, and increased social isolation (Oexle et al., 2016;

Seeman et al., 2016; Stuart, 2016).

Studies have shown that stigma around mental illnesses is at its greatest prevalence for

mental illnesses that are less understood (Fox et al., 2018; Klein et al., 2021; Oexle et al.,

2016; Seeman et al., 2016; Stuart, 2016). Borderline Personality Disorder (BPD) also known

as Emotionally Unstable Personality Disorder (EUPD) is not as commonly diagnosed as other

mental illnesses such as depression and anxiety. Therefore, it is plausible to assume that the
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lack of understanding and awareness around BPD may lead to people with the condition

facing stigma (Biskin, 2015; Bohus, et al, 2021; Dardas & Simmons, 2015; Gunderson, J.G.,

2016; McDowell & Fossey, 2015; Roy, et al., 2020).

For the purpose of this study, references of BPD will cover both Borderline Personality

Disorder and Emotionally Unstable Personality Disorder.

1.2 Research Aims

This study aims to explore the level of stigma people with BPD may experience. The

anticipated benefit of this study is to support other research in the field and raise awareness of

BPD and help reduce the stigma towards it. The findings of this study may help to increase

our knowledge of understanding mental illnesses, reducing conscious of unconscious stigma

towards people with BPD as well as supporting other students in the future with their

research in similar areas.

1.2 Research Questions

Research question 1: Is there stigma towards people with BPD from a normative population?

Research question 2: What are the contributing factors that cause stigma towards people with

BPD?

2.0 Literature Review

This section will explore mental illness, BPD, and stigma. Published literature for

2015 onwards will be critically reviewed to determine the connection between BPD and
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stigma. Literature review plays a crucial role in research. Since BPD is a complex and

multifaceted mental health condition, conducting a thorough review of existing literature on

the topic is essential for my project as outline below.

1) Helping me to gain a comprehensive understanding of BPD, including its symptoms,

causes, risk factors, and treatment options. This knowledge would be vital for designing my

research questions, selecting appropriate methodologies, and interpreting my research

outcomes.

2) Helping me to identify gaps in my existing knowledge, guiding my research focus. By

examining the current state of research on BPD, I could potentially be able to identify areas

where further research is needed and design studies that address these gaps.

3) Helping me to develop critical thinking skills and enhance my ability to evaluate and

analyse research findings, hence improving my own rigor and validity of my own research.

4) Helping me to situate my research within the broader context of BPD research to gain

a deeper understanding of BPD.

2.1 Borderline Personality Disorder

Borderline Personality Disorder (BPD) is a mental health condition characterized by

unstable mood, behaviour, and relationships. Individuals with BPD often struggle with

emotional regulation, self-image, and interpersonal interactions. BPD is typically diagnosed

based on a pattern of symptoms, which may include intense and sudden mood swings,

difficulty controlling anger, fear of abandonment, unstable relationships, self-harming

behaviours, impulsivity, chronic feelings of emptiness, and a distorted self-image.

(Gunderson et al., 2018; Paris, 2019). BPD is one of ten personality disorder that can be
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diagnosed in the UK (Volkert et al., 2018). A study by Winsper et al., (2019) found that the

worldwide prevalence of BPD may be as high as 2.8%.

BPD is known to be challenging to both diagnose and treat (Campbell et. Al., 2020;

Paris, 2019; Zimmerman & Morgan, 2022). Approximately 20% of psychiatric inpatients

have a diagnosis of BPD (Comtois & Carmel, 2016; Fossati, 2015). The impact on untreated

BPD can be devastating, with non-suicidal self-injury (NSSI) and suicidal behaviour being

common in people with a BPD diagnosis (Greenfield et al., 2015; Klein et al., 2021; Kuehn

et. Al., 2020; Reichl & Kaess, 2021).

2.2 Stigma and Mental Health

There has been significant research on mental health and stigma. Bharadwaj et al

(2017) found that people were significantly more likely to not report mental health illnesses

than physical illnesses due to concerns of stigma. In a study of 423 adults, the researchers

found that mental health stigma both directly and indirectly affected treatment attitudes and

physical health (Sickel et al., 2019). Similarly, a third of the adults with mental health

problems have reported concerns around confidentiality and the negative impact of their

illness on their career while 10% of the study population were not aware of resources to get

support on their mental illness (Haugen et al., 2017). The availability of supportive

information has been shown to positively impact stigma on mental health issues. A small but

an important study underlines the relationship between availability of information and degree

of stigma on mental illnesses. In this study, thirty-nine university students participated who

completed a pre- and post- questionnaire after being provided with information on mental

illnesses. The results showed a statistical significance in the median decrease in mental health
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stigma in the post- questionnaire. This study supported the idea that providing knowledge and

information on mental illnesses can help reduce mental health stigma (Simmons et al., 2017).

Mental health stigma appears to be a world-wide issue. A study investigating

perceived mental health stigma in Latino and African American university students found

that both groups where people had mental health difficulties, had anxiety about mental health

stigma. However, African American students had higher rates of mental health stigma than

Latino students, indicating potentially social-based aspect of stigma (DeFreitas et al., 2018).

Similarly, a study in a Chinese population reported a large population of the community held

negative beliefs towards people with a mental health condition. Importantly, authors reported

mental health knowledge as low while public stigma towards mental health was significantly

high (Yin et al., 2020). Therefore, it is reasonable to suggest that stigma surrounding mental

health can manifest in several ways as outlined below:

1. Social stigma: involves negative attitudes and discriminatory behaviours from others

in society. People with mental health conditions may face prejudice, discrimination, and

exclusion from social activities, housing, employment, and relationships due to the

misconceptions and fear associated with mental illness (Simmons et al., 2017).

2. Self-stigma: occurs when individuals with mental health conditions internalize the

negative stereotypes and beliefs associated with mental illness. They may feel ashamed,

guilty, or inferior, leading to self-blame, low self-esteem, and reluctance to seek help for fear

of being judged or rejected (Bharadwaj et al., 2017)

3. Structural stigma: refers to discriminatory policies, practices, and systems that are

embedded in institutions, such as healthcare, education, and employment, which limit the

opportunities and resources available to individuals with mental health conditions. Structural
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stigma can result in inadequate access to mental health care, inequities in treatment options,

and disparities in health outcomes (Sickel et al., 2019; Haugen et al., 2017).

Structural stigma was investigated by Klein et al., (2022) and found that structural stigma

was extremely present towards people with BPD and caused a substantial negative impact on

people with BPD accessing health services. The study found that structural stigma came from

the diagnosis of BPD and other BPD-related stigma surrounding health care services. The

researchers concluded that further research, training, and policies were needed in health care

settings in order to eradicate structural stigma towards people with BPD.

2.3 Stigma and personality disorders

There are numerous reports indicating that BPD has historically been misunderstood

and stigmatized due to its complex and challenging nature. It is important to approach

individuals with BPD with empathy, understanding, and without judgment. Educating oneself

about BPD and promoting mental health awareness can help reduce stigma and promote

compassionate care for those with BPD. Similarly, research has investigated stigma and BPD.

Public knowledge of BPD is low, and society generally saw people with BPDs as

‘misbehaving’ instead of it being a symptom of mental illness More importantly, the authors

reported significant level of stigma from clinicians towards people with BPD (Sheehan et al.,

2016).

Stigma around BPD by healthcare workers is a significant issue that could potentially

have serious negative impacts on patients with BPD and their ability to access appropriate

care. Numerous researchers have further highlighted that a significant level of the stigma

towards people with BPD originates from the health care workers. A study by Klein et al.,

(2021) found that there is significant institutionalised sigma towards people with BPD,
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especially in emergency departments, in comparison to perceptions towards people with other

diagnosed mental illnesses. There are several reasons why healthcare workers may stigmatize

individuals with BPD such as those outlined below (Knaak et al., 2015; Sheehan et al., 2016;

Ring and Lawn 2019; Klein et al., 2021).

1) Lack of understanding: BPD is a complex mental health condition that can be

challenging to understand. Healthcare workers may not have sufficient knowledge

or training about BPD, leading to misconceptions and misunderstandings, which

can contribute to stigma.

2) Emotional intensity: Individuals with BPD may display intense emotions,

including anger, impulsivity, and distress. Healthcare workers who are not trained

to manage and understand these intense emotions may view patients with BPD as

difficult or challenging to work with, leading to stigmatizing attitudes.

3) Challenging behaviours: BPD is often associated with impulsive behaviours, self-

harm, and suicidality. Healthcare workers may find these behaviours distressing

and may respond with negative attitudes or stigmatizing beliefs about individuals

with BPD.

4) Labelling and bias: Labels such as "manipulative," "toxic," or "difficult" are

sometimes used to describe individuals with BPD, which can perpetuate stigma

and negative attitudes among healthcare workers (Widuch, 2021). This labelling

can also lead to biased treatment and less empathetic care.

The researchers reported significant gaps in BPD knowledge which in turned

generated high levels of stigma. An interesting study by Ring and Lawn (2019) has identified

six themes connected to stigma; 1) stigma connected to disclosure and diagnosis, 2) perceived

un-treatability, 3) stigma as a reaction to feeling helpless, 4) preconceptions of people with

BPD 5) lack of knowledge around BPD and 6) prevail over stigma through empathy. The
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equational training appears to be an important mitigating strategy towards healthcare workers

originated stigma. Studies reported that training significantly decreased clinician’s stigma

towards people of BPD, further underlining hypothesis that training and education around

BPD can help reduce stigma significantly (Knaak et al., 2015; Sheehan et al., 2016; Klein et

al., 2021).

Similarly, Ring and Lawn (2018) investigated stigma towards people with BPD from

both patient and clinician perspectives. The study found that poor health literacy on BPD was

the main factor that contributed to stigma towards people with BPD. They found that poor

health literacy contributed to ineffective treatment and engagement and suggested that

targeted education and advocacy is needed to address the stigma.

A study investigated BPD and the involvement people with BPD had with the

criminal justice system and found that crimes committed came from the inability to control

impulsive behaviour. The study also found that the more contact a person with BPD had with

the criminal justice system, the more likely they were to increase impulsive behaviour. The

study concluded that people with BPD were less likely to act out of heightened emotions and

impulsivity if the involvement of the criminal justice system were not involved (Moore et al.,

2017).

3.0 Methodology

This section will review and discuss the methodology of the research study and will

include how crucial decisions were made which may have impacted the overall research

study and finding. The significance of ethics and philosophy will also be discussed. The

methodology of a research study on for example on my research here on borderline

personality disorder (BPD) would play a critical role in shaping the outcomes of the study
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and its impact on understanding the disorder. The right methodology can help produce

reliable and valid findings that can improve understanding of BPD and impact patient care.

The following considerations will impact methodology of my research on BPD:

1. Study design: Can affect the study's validity, accuracy, and generalizability.

2. Sample selection: Right methodology is vital in identifying people with BPD

and ensuring that the study is relevant and representative of the disorder.

3. Data collection methods: Using various methods to collect data, such as

structured interviews, questionnaires, and observations can impact on validity and accuracy

of the data obtained, and the conclusions.

4. Data analysis: The methodology used to analyse data can affect the reliability

of the results, including the statistical techniques.

5. Implication and generalization: and finally, study's implications and

generalizations are based on the results, hence right methodology used can ensure

generalizability of the data.

3.1 Philosophy

Philosophy can be defined as the fundamental base of metaphysics, epistemology, and

ethics (American Psychological Association, 2023). Research philosophy helps determine a

scientific study including what strategic approaches to take and the affects that a chosen

strategy will have on the research conducted (Saunders et al., 2015).

Metaphysics is a sub-section of philosophy that focus on the nature of reality and can

be described as the most abstract division of philosophy (American Psychological

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Association, 2023). Metaphysics can be split into two sub-areas: ontology and subjectivism.

Ontology is the philosophical approach that objectively answers the question of existence

factually, whereas subjectivism answers research based on an individuals’ personal emotions

and thinking (American Psychological Association, 2023). For this study, a subjectivist

approach was taken to understand study participants felt stigma.

Epistemology is the theory of knowledge and understanding in methodology

justification. Thematic analysis is a research approach that has five steps in analysing

research. It is used to identify and ascertain theme patterns within qualitative research. This

form of analysis is an ideal approach for this study as it allows for understanding of common

themes amongst study participants which will allow a result to answer the research questions

as opposed to having multiple varied conclusions (American Psychological Association,

2023, Vaismoradi et al., 2016).

Inductive and deductive are the two primary research categories. Inductive is where

there is little to no research on the area of interest and is based on observations, whereas

deductive research is research that investigates a theory that may have already been

previously explored. For the purpose of this study, a theory has been generated (the

relationship between stigma and BPD) based on previous literature in the subject matter.

Questions have then been generated which will be investigated by conducting a semi-

structured interview with study participants. Therefore, this study is a deductive research

study (American Psychological Association, 2023; Bingham & Witkowsky, 2022).

3.2 Strategy

Probability and non-probability are the two primary sampling techniques. Probability

sampling is the umbrella sampling technique for random participant selection whereas non-
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probability sampling are processes where study participants are chosen more purposefully

(American Psychological Association, 2023). For this study, non-probability sampling was

chosen as participants need to fit a specific criterion (be an adult in the North West of

England and have heard of BPD but do not have a diagnosis of it) to partake in the research.

The criteria for this study were selected to answer the research questions and

investigate stigma towards people with BPD. Purposive snowball sampling was used for the

purpose of this study as it offers the ability to select candidates who meet the study criteria

while also allowing to engage with more study participants across the North West of England

who meet the criteria required (American Psychological Association, 2023; Sharma, 2017).

Qualitative data collection is a great strategy that yields descriptive data and provides

data collection that allows examination of how individuals perceive the world (BPD) from

their own personal accounts of experiences. This method was chosen to delve into study

participants views, thoughts, and feelings towards BPD to identify whether signs of stigma

prevail (American Psychological Association, 2023). This supports the focus of the study and

allows for emotive data collection. A semi-structured interview was used to allow for a base

line of questions to ask to answer the research questions, whilst also allowing for further

questions to be added during the live interviews to prompt study participants to share more of

their thoughts and feelings.

3.3 Methods

A semi-structured interview guide containing 22 pre-determined questions was used.

The interview guide was created to work as a starting point for the interviews, while allowing

for lots of room for additional prompt questions to be asked that are relevant to each
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individual participant while permitting suitable data collection. A participation information

sheet was constructed to outline the research project and also provide informed consent.

Twelve participants were initially recruited for this study. Three participants withdrew

themselves from participation and one study participant revealed they previously have had a

diagnosis of BPD so was not eligible to take part. Seven adults in the borough of Merseyside

and one adult in the borough of Greater Manchester were fully recruited for this study. Data

was collected between 6th April to 7th April. Participants were verbally approached and/or via

snowball sampling. Upon participants confirming their interest, each person was provided

with the participation information sheet and the consent form which required participant

signature before proceeding. A mutually agreed date and time were arranged with each

participant for the semi-structured interview to take place using Zoom (2023).

3.4 Generalizability

In this study, participants were chosen that had lived in the North West of England,

had heard of (but not had a history of) BPD/EUPD and over the age of eighteen. All other

factors including gender, educational background, career, hobbies, and interests for example

were not factored into participation selection. This was done to gain a true representation of

people with BPD in the North West of England. However, it can be acknowledged that due to

small sample sizing, the results obtained may not be easily replicated across the United

Kingdom. All study participants advised they are currently employed, meaning that data

collected is not necessarily representative of a normative population. Furthermore, all study

participants identified as female so is more likely to be a representation of a female

population than a generalised normative one. Therefore, it would be merited to repeat this

study on a larger scale to further evaluate the research questions to improve generalizability.
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3.5 Reliability

Reliability is a crucial aspect of any research study, including this study researching stigma

towards people with borderline personality disorder. Reliability refers to the consistency and

accuracy of the results obtained from a study. A reliable study can increase the validity of the

research, inform clinical practice and public policy, and provide accurate information about

the impact of stigma on individuals with borderline personality disorder.

In this study, reliability is essential for several reasons. First, the study's results should

be consistent to ensure that the findings are not due to chance or errors in data collection.

Second, reliable results increase the confidence in the study's conclusions and the validity of

the research. Finally, a reliable study can help to inform clinical practice and public policy by

providing accurate information about the impact of stigma towards individuals with BPD. To

ensure the reliability of a research study, it is essential to use standardised methods for data

collection, such as validated measures and protocols. Moreover, using a large sample size

would increase the statistical power of the study and conduct the research in multiple settings

to ensure that the results are generalizable. Therefore, reliability is a critical aspect of any

research study, and it is especially important in this research.

3.6 Limitations

As with any research study, the research on the stigma surrounding BPD may have some

limitations which are highlighted below.

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1) Limited sample size: availability of limited resources and access to a small sample

size, may have affected the generalizability of the findings. The results obtained from

a small sample size may not be representative of the larger population of individuals

with BPD or those who experience stigma related to BPD.

2) Sampling bias: The participants recruited for the study may not be fully representative

of the target population therefore, the findings may not accurately reflect the

experiences of individuals with BPD in other settings or from diverse populations.

The use of snowball sampling may also contribute to sampling bias due to study

participants being chosen through a non-probability sampling method.

3) Self-report bias: Stigma is a sensitive and complex topic, and individuals may

underreport or overreport their experiences of stigma, depending on various factors

such as social desirability bias or recall bias. This may affect the accuracy and

reliability of the data collected in this study.

4) Cross-sectional design: due to limited time and resource constraints, a cross-sectional

design was utilised where data was collected at a single point in time. This design

may limit the ability to establish causal relationships or capture changes in stigma

experiences over time.

5) Limited research experience: the research limited experience in conducting research,

which could impact the quality of the study. The researcher’s experience in study

design, data collection, data analysis, and interpretation of findings are limited which

could impact reproducibility and data accuracy of this study.

6) Ethical considerations: The researcher encountered challenges in navigating ethical

issues related to conducting research on this sensitive topic which could impact the

validity and reliability of the findings.

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7) Resource constraints: The researcher had a limited resource, including time, funding,

and access to research tools or expertise. These limitations may impact the scope and

quality of this study.

3.7 Data Analysis

Data was collected using Zoom (2023) with participant agreement so that the

interviews were easily recorded, ensuring reliable transcription of the interviews and accurate

information recall. Data is stored on a secure device with password protection encryption that

only the researcher has access to. Data analysis was conducting using thematic analysis to

identify patterns in the collected data to ascertain whether there is stigma (and to what extent)

towards people with BPD.

Thematic analysis was used in order to discover, analyse and make sense of themes

and patterns from the data collected. It involves several steps. Firstly, reviewing the

transcripts so that the researcher became familiar with the data. Coding was then conducted

to identify the themes across all eight transcripts. A minimum of half of the transcripts (n=4)

had to include the same theme for it to be considered as a result of this study. Patterns and

codes were then reviewed again to identify and conclude on the themes from the data

collection.

3.8 Ethics

Ethics play a crucial role in research on stigma surrounding BPD. BPD is a mental

health condition that is often stigmatised, leading to negative attitudes, beliefs, and
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discriminatory behaviours towards individuals with BPD. Conducting research on stigma in

BPD requires careful consideration of ethical principles to protect the rights and well-being

of participants and ensure the integrity and validity of the research findings.

In doing this study following key points were considered:

1) Protection of participant rights: Ethical research requires obtaining informed

consent from participants, which means that participants must be fully informed

about the nature, purpose, risks, and benefits of the research before they can

voluntarily decide to participate. Individuals may be vulnerable if they have other

mental health conditions, and researchers must ensure that they are treated with

respect, confidentiality is maintained, and their rights are protected throughout the

research process.

2) Minimization of harm: Research on stigma can potentially expose participants to

emotional distress. Researchers need to be mindful of the potential harm and take

steps to minimise it, such as providing appropriate support, debriefing, and

referrals to mental health services for participants who may need them.

Participants were reminded that participation was voluntary and were also advised

of their right to withdraw their collected data up until the research project has been

submitted. To set expectations and minimise any distress, participants were

informed that they were invited to participate to discuss their thoughts, feelings,

and views towards people with BPD during a semi-structured interview.

Participants were also offered a debrief form with information and advice on

services to access support to protect participant welfare. The welfare of the

researcher was also maintained by conducting the interviews virtually.

3) Confidentiality and privacy: Stigma-related research may involve sensitive and

personal information shared by participants. Researchers must adhere to strict

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guidelines to protect the confidentiality and privacy of participants, ensuring that

data collected is stored securely and reported in a way that does not reveal the

identity of the participants. All identifiable features of the participants were

anonymised to protect participant confidentiality and comply with GDPR. No data

was accessible to anyone outside of the research team.

4) Avoidance of perpetuating stigma: Researchers must be mindful of not

inadvertently perpetuating stigma during the research process. This includes

avoiding the use of stigmatising language, promoting accurate and balanced

representations of BPD, and taking measures to challenge and reduce stigma

through the research findings and dissemination of results.

5) Rigor and validity of research: Ethical research practices are essential to ensure

the rigor, validity, and reliability of research findings. Adhering to ethical

guidelines and standards enhances the credibility of the research and strengthens

the trustworthiness of the findings, which can have a significant impact on the

field of BPD research and contribute to evidence-based interventions and policies

to reduce stigma.

6) Ethical approval: This study has been approved by the Liverpool Hope University

Psychology Ethics committee before commencing the study. To ensure participant

safety and dignity, all aspects of the study and data collected were reviewed and

approved by the ethics committee upon completion of the electronic ethics

approval form.

In conclusion, ethics are of paramount importance in research on stigma surrounding

BPD. Ethical considerations ensure the protection of participant rights, minimisation of harm,

confidentiality and privacy, avoidance of perpetuating stigma, and rigor of research findings.

Moreover, ethical research practices are crucial for generating accurate, reliable, and valid
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knowledge that can contribute to reducing stigma and improving the lives of individuals with

BPD.

4.0 Findings

This section explores the results and data collected. Results were analysed to

determine whether the participants experienced stigma due to their diagnosis (and to what

extent) and where experienced stigma resonates from.

4.1 Study Participants

Three people withdrew from the study before taking part in the semi-structured

interview and upon interviewing a particular participant, data was discarded as they did not

meet the study criteria as the participant had previously been diagnosed with BPD. Therefore,

eight females participated in this study. The study participants were aged between 25-48. The

below table summarises the job roles of the study participants.

Table 1: Job Roles of Study Participants

Study Participant Job Title

Participant 1 Admin Assistant

Participant 2 Support Worker

Participant 3 Recruitment Officer

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Participant 4 Teacher

Participant 5 Medical Secretary

Participant 6 Recruitment Officer

Participant 7 Recruitment Officer

Participant 8 Sales Assistant

4.2 Results

The use of thematic analysis produced seven main themes: 1) Understanding Stigma

2) Bipolar Disorder 3) Anger 4) Emotional Instability 5) Trauma 6) Negative Perceptions 7)

Education. This section discusses the themes found with relation to the research questions.

4.2.1 Understanding Stigma

A pre-designed question was asked to identify study participants understanding of

stigma. There were mixed levels of understanding and knowledge of stigma. Participant 8

showed the greatest understanding of stigma, and described it as…

“…stereotyping or bias. Seeing a certain group of people in a negative way.”

(Participant 8).

Participant 6 also appeared to have a strong understanding of stigma and explained

that stigma is…

“…what you associate with a particular condition.” (Participant 6).

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Multiple participants admitted they did not understand what stigma was:

“I don’t know.” (Participant 1).

“I’m not sure.” (Participant 4).

“I’ve not got a clue about it.” (Participant 5).

One participant believed they knew the understanding of the word stigma but gave an

incorrect explanation:

“The way you have to act or behave…” (Participant 7).

4.2.2 Bipolar Disorder

A common theme amongst half of the study participants was Bipolar Disorder. Some

study participants mentioned the disorder when talking about and explaining BPD:

“…I kind of associate it with Bipolar…” (Participant 2).

“I don’t know if it’s a bit like Bipolar.” (Participant 3).

“For example, they’ve got Bipolar, so they must be depressed.” (Participant 4).

“I don’t know if it’s quite close to Bipolar or not ‘cos (sic) I know sometimes you can

have like really, like heightened or really low emotions and stuff. But I don’t know if that’s

right.” (Participant 5).

4.2.3 Anger

Anger was very prevalent amongst the study participants when describing a person

with BPD:
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“They might feel angry and annoyed.” (Participant 1).

“”…maybe they’re angry one minute and that then they’re okay the next.”

(Participant 3).

“I would say uncontrollable anger at times.” (Participant 4).

“Might be a bit angry at certain situations like get angry more easily than a non-BPD

person would.” (Participant 6).

“I’d have said emotionally unstable, acting without thinking, anger…” (Participant 6).

“I feel like just a lot of like anger or inability to control certain behaviours.”

(Participant 8).

4.2.4 Emotional Instability

Emotional instability was the most commonly used description used by all of the

study participants when discussing people with BPD. Its prevalence was substantial

throughout all of the data collected with all participants commenting on it:

“I feel like they might feel okay one moment and then they might feel a bit sad or

their mood might change dead quickly all of a sudden.” (Participant 1).

“…unable to regulate their emotions. Erm…some sort of mood dysregulation.”

(Participant 2).

“I don’t know if they can go from hot and cold…” (Participant 3).

“Their attitude can flick very quickly from one to the other.” (Participant 4).
 29

“I would say like obviously maybe at times they could be like intensely happy and

you know really enjoying life and stuff like that but then all of a sudden just that they can hit

a significant low…” (Participants 5).

“…I’d probably say emotionally unstable maybe or they’re acting out or they’re

angry…” (Participant 6).

“I would think that they would be very unstable in their emotions. So like one time

they might be up and another time the might be down.” (Participant 7).

“…trouble controlling and understanding self-emotions.” (Participant 8).

4.2.5 Trauma

Another theme that was recognised in most of the data collected was trauma.

Participants talked about trauma and its association with people with BPD:

“…something could just trigger them or it could be like a past trauma in their life…”

(Participant 1).

“…maybe something regarding their past. If they’ve got like a traumatic childhood.”

(Participant 2).

“I do think that a lot of it comes from their childhood traumas and things that have

happened in their pasts…” (Participant 4).

“I would say someone who has struggled with significant trauma throughout their life

or like has had some sort of traumatic experience that’s led to them to unfortunately develop

BPD.” (Participant 5).

 30

“…maybe someone who has had something in their childhood that’s caused it to

happen maybe. Like a trauma in their childhood or something maybe.” (Participant 6).

4.2.6 Negative Perceptions

This study was created to investigate stigma towards people with BPD. Using both the

pre-designed questions and prompt questions, the researcher was able to identify negative

perceptions in the data collected:

“They were more than likely known as the disruptive child…” (Participant 3).

“…narcissism can be a trait I think.” (Participant 3).

“…this is just my point of view but they can be very manipulative as well…”

(Participant 4).

“I couldn’t put myself in that situation where I am an emotional punching bag for

somebody.” (Participant 4).

“Make sure you’re always careful around them.” (Participant 7).

“My instant reaction is [that they are] quite like selfish. I can’t say more specific than

that.” (Participant 8).

A common thought of how the study participants described a person with BPD was

unstable, with half the participants using this word as a descriptive of a person with BPD. An

example of this is below:

“Sometimes unstable. I mean, I don’t know. Emotionally volatile.” (Participant 8).

Study participants were asked a pre-designed question about what crime do they think

someone with BPD is most likely to commit. This question was asked to understand what
 31

study participants thoughts and views were about BPD and criminal activity. Half of the

study participants believe that the most commonly committed would be of a serious, violent

nature:

“I’d probably say getting into fights. So, like assault. Because I could imagine if

you’ve got any type of disorder that affects your personality that can get you into trouble…”

(Participant 3).

“…abuse to somebody else.” (Participant 5).

“…as they’re emotionally unstable that depending on what they’re feeling so if it’s

anger it could lead to murder. Even not just murder but physically attacking someone. I think

that that’s probably what I would feel would be the main crime.” (Participant 7).

“…something more like assault.” (Participant 8).

4.2.7 Education

Education was another prevalent theme within the data collected. All study

participants mentioned the need and benefits of education to reduce stigma towards people

with BPD:

“…creating a greater understanding to people that have no knowledge…on the news.

Advertisements and that. On the media.” (Participant 1).

“…one good way is on TV isn’t it. To have more people on TV that have it…I think

being in the public eye is a massive thing.” (Participant 3).

“…education. Learning. Reading up on it and being open minded. Not being scared

and talking about it, you know, ask people what it’s like…” (Participant 4).
 32

“Educate yourself. So, learn a bit more about it instead of maybe meeting someone for

the first time and seeing them in a bad way. Educate yourself about it…The main one will be

the internet. There are thousands of websites. Obviously, you’re looking for more like a

psychology based or NHS website or something maybe. Not like any random website. A

good source.” (Participant 6).

“…social media.” (Participant 7).

“More awareness. More knowledge about it….maybe start at schools to start off

with…” (Participant 8).

5.0 Discussion and Conclusions – Do not touch discussion section until Jane feedback

This section will provide an in-depth discussion on the results within the context of

published literature and the data collected in this study. This section will also provide a

conclusion to summarise the study findings. Male / female views how stigma might be

different between genders as I only interviewed females

5.1 Discussion

Stigma can have a significant impact on the lives of those affected by mental health

issues, including BPD, and it is important for individuals to have a clear understanding of

what stigma is and how it can affect people (researched (Klein et al., 2021; Knaak et al.,

2015; Ring & Lawn, 2019; Sheehan et al., 2016). This understanding can help to reduce the

negative effects of stigma, including barriers to accessing appropriate care, feelings of shame

and isolation, and difficulty with social and occupational functioning.

 33

Stigma impact can include barriers to accessing appropriate care, difficulty with social

and occupational functioning, and increased feelings of shame and isolation. Furthermore,

research has shown that people with BPD are at increased risk of non-suicidal self-injury

(NNSI) and suicidal ideation, which makes de-stigmatization even more important (Klein et

al., 2021). This risk emphasizes the need for effective treatment and support for individuals

with BPD. The significance of de-stigmatisation is especially important to clinicians as they

play a vital part in supporting people with BPD in clinical settings. Therefore, it is essential to

continue to raise awareness of the impact of stigma on mental health and BPD, and to work

towards creating a more accepting and supportive society for those affected by these issues.

In this study, all study participants were asked to provide their understanding of

stigma. Responses were varied, with only two participants (n=2) having a strong

understanding of what stigma was. The remaining participants (n=6) either advised they did

not know what stigma was or provided an incorrect explanation. As a result, it is reasonable

to suggest that only a small number of study participants had a strong understanding of what

stigma is, while the majority either did not know or provided incorrect explanations. This

highlights a need for increased education and awareness around the topic of stigma,

particularly in relation to mental health and BPD (Winsper et al., 2019; Yin et al., 2020).

Considering these results, it is reasonable to suggest that moving forward, efforts should be

made to increase education and awareness around the topic of stigma, particularly in relation

to mental health and BPD.

As the none of the participants were clinicians it would be reasonable to suggest that

one way to do this would be public education campaigns to raise awareness of the impact of

stigma and promote more accepting and supportive attitudes towards individuals with mental

health issues. Furthermore, as clinicians play a crucial role in supporting people with BPD in

clinical settings another suggestion would be to have targeted educational programs for
 34

healthcare professionals. As part of the clinician’s role involves addressing the stigma that

surrounds this disorder these educational programs could help to improve outcomes for those

affected by BPD by allowing clinicians to more effectively advocatr for improved access to

care as a result of reduced stigma (Klein et al., 2021; Knaak et al., 2015; Ring & Lawn, 2019;

Sheehan et al., 2016).

Bipolar disorder is a psychiatric condition that can be characterised by strong periods

of mania and depression (NHS, 2023). Bipolar disorder is characterized by episodes of mania

or hypomania alternating with episodes of depression, while BPD is a personality disorder

characterized by difficulties with emotion regulation, self-identity, and interpersonal

relationships (NHS, 2023). In this study 50% of the study participants made connections

between BPD and bipolar disorder, advising bipolar disorder and BPD as being similar

conditions. This suggests a lack of understanding about the differences between these

conditions and highlights the need for increased education and awareness about the specifics

of mental health conditions. Improving education and awareness around mental health

conditions can help to reduce the stigma and misunderstandings associated with them,

leading to more accurate diagnoses and better treatment outcomes (Purcell et al., 2019;

Volkert et al., 2018; Winsper et al., 2019). As previously mentioned, efforts to increase

education and awareness can include public education campaigns, targeted education for

healthcare professionals, as well as increased access to resources and support for individuals

affected by mental health conditions.

There have been various studies about the association between anger and BPD.

People with BPD are more likely to experience anger and exhibit aggressive behaviours

(Martino et al., 2017). The authors suggested an important link between BPD and targeted

anger reduction in treatment for BPD may help to reduce aggressive behaviour in this

population. Similarly, Bach and Farrell (2018) using schemas, found that the mode of ‘angry
 35

child’ was predominant in their population (n=101) of people with BPD. The "angry child"

mode is associated with feelings of anger, frustration, and vulnerability. In this study, anger

was a common theme reported with all study participants. Result of this study agrees with

previous reports indicating that BPD patients exhibited higher states of anger than healthy

control and even patients with ADHD (Bach and Farrell, 2018). Furthermore, angry thoughts

were a significant predictor of aggression proneness. Importantly, the anger level was stress-

dependent, and signified that a higher stress level resulted in a greater intensity of anger. In

addition, authors reported that aggression and anger were positively correlated with emotion

regulation deficits in patients with BPD (Francesca Martino et al., 2015; McGonigal &

Dixon-Gordon 2022; Sylvia Cackowski et al., 2017; Lobbestael and McNally 2016).

Another study has reported that in patients with BPD, frustration-induced anger is

independent of emotional dysregulation underlining the importance of focused anger

management interventions (Katja Bertsch et al., 2021). Therefore, based on these studies, it is

reasonable to suggest that more research is needed to better understand the relationship

between anger and BPD and to develop effective interventions for addressing anger and

aggressive behaviour in individuals with this condition.

Emotional instability is one of the defining features of borderline personality disorder

(BPD) and is often cited as a key characteristic in the literature (Biskin, 2015; Bohus, 2021;

Campbell et al., 2021). In this study, all participants identified mood swings, emotional

dysregulation, and intense unstable emotions as common features of BPD, which is consistent

with the clinical presentation of the disorder. It is important to note that while the study

participants may not have had an in-depth understanding of BPD, their identification of

emotional instability as a key feature is important. Emotional instability can significantly

impact an individual's functioning and quality of life and can be a significant challenge to

manage in therapy. Identifying and addressing emotional dysregulation is often a key focus of
 36

treatment for individuals with BPD, and understanding the impact of emotional instability on

the individual and those around them is an important step in developing effective

interventions.

Prolonged and severe trauma, particularly trauma that occurs early in the life cycle,

tends to result in a chronic inability to modulate emotions (Van der Kolk et al., 1994).

Trauma can have a significant impact on an individual's mental health and can increase their

risk of developing BPD, hence it has become a common theme in the research on BPD. The

most accurate theoretical models appear to be multifactorial, considering a range of factors,

including early trauma, to explain evolutionary pathways of BPD. There are numerous

studies indicating a link between traumatic experiences and the development of BPD (Cattane

et al., 2017; Luyten at al., 2019; Yuan et al., 2023).

The role of alterations in childhood trauma-associated vulnerability has strong links to

developing BPD (Cattane et al., 2017). By acknowledging the role of trauma in the

development of BPD, clinicians can better understand their patients' experiences and develop

more effective treatment plans. Trauma-informed care, which emphasises the importance of

understanding and addressing trauma in treatment, has become increasingly popular in recent

years and is an essential component of effective treatment for BPD (Bozzatello et al., 2021).

In this study, half of the study participants demonstrated knowledge and understanding that

BPD can be caused by trauma and/or childhood experiences. This indicates a growing

awareness of the impact of traumatic experiences on mental health and highlights the

importance of addressing trauma in the treatment of BPD. Thus, it is important to continue to

raise awareness of the link between trauma and BPD and to incorporate trauma-informed

approaches in the treatment of individuals with BPD.

 37

There has been significant research conducted on the stigma associated BPD. Many

studies have shown that individuals with BPD face negative attitudes, discrimination, and

stereotypes from others, including mental health professionals. Several participants explicitly

or implicitly expressed negative attitudes towards people with BPD, despite acknowledging

that their understanding of stigma was limited. This highlights the complex nature of stigma

and how it can affect people's beliefs and attitudes towards mental health conditions

((Fossati, 2015; Haugen et al., 2017; Klein et al., 2021; Knaak et al., 2015). BPD is often

regarded negatively by mental health practitioners and the public highlighting a strong stigma

associated with it. The stigma associated with BPD affects practitioners’ tolerance, believes,

actions, and emotional reactions towards patients with BPD (Aviram et al., 2006). The results

of this study are in line with the findings of previous reports outlining that stigma is not only

strongly present towards patients with BPD, but it also profoundly impacts lives and well-

being of patients with BPD. Therefore, it is essential to recognize the harmful impact of

stigma on individuals with BPD and other mental health conditions, as it can create barriers

to seeking help, lead to social isolation, and negatively affect one's self-esteem and sense of

identity.

Another strong pattern across the data collected was the need for education to remove

bias and stigma towards people with BPD. Many different approaches to education were

advised by the different study participants but most agreed that education was a vital

component in increasing societal understanding and awareness of BPD and decreases stigma.

Thus, more research, education and awareness campaigns are needed to combat stigma and

promote a more empathetic and supportive approach towards people with BPD and other

mental health conditions.

 38

5.2 Conclusion

There is ongoing stigma towards people with BPD, despite increasing awareness and

understanding of mental health. It is crucial to recognise that stigma is often rooted in

misinformation, lack of education, and societal stereotypes, and addressing these underlying

factors is necessary to combat it effectively. The most important point to note is that those

displaying signs of stigma towards people with BPD are not aware of their own negative bias

towards people with BPD. Education and awareness campaigns are crucial in reducing stigma

towards BPD and other mental health conditions. These efforts can involve various

approaches, such as increasing public knowledge about BPD, promoting positive descriptions

of people with BPD in the media, and offering training to healthcare providers and other

professionals to reduce biases and negative attitudes.

This study contains a large limitation that may impact on adequate data collection. A

small sample size and a lack of diversity in the participant pool can significantly limit the

generalizability of the findings. For instance, in this study, all participants were females and

in employment suggesting that it is not a true representation of the society. Therefore,

conducting larger studies with more diverse samples can help provide a more comprehensive

understanding of the issue and its potential solutions.

6.0 Recommendations and Impact

This section explores recommendations based on the study findings to help reduce

stigma towards BPD.

6.1 Recommendations
 39

The following recommendations have been suggested to help make positive change in

society:

1) Conduct a follow-up study with a larger population to assess and identify the validity

of this study and further learn the extent of stigma towards people with BPD in a

normative population.

2) Increase education of mental health conditions in academic environments. Introduce

or improve life skills lessons for schools on the topic of mental health and wellbeing

and include signs, symptoms, and information and advice on all mental health

conditions including BPD.

3) Provide training to management, recruitment, and HR in organisations on mental

health conditions so that those with staff wellbeing responsibilities have a greater

understanding on mental health conditions. This should also include training on

understanding unconscious bias so that employers are aware of their own personal

bias’s and can then support their employee’s and potential candidates joining the

organisation.

4) Provide more accessible mental health first aid training and include specifics around

mental health conditions such as BPD as well as ensuring organisations have a Mental

Health First Aider so that anyone who is struggling with BPD know there is a

dedicated person there who is trained to support them through mental health

challenges during work.

5) Advertise factual and informative information about BPD using social media and TV

adverts so that the wider public have access to correct information to help encourage

talking about mental health and help remove barriers and stigma towards people with

BPD.
 40

6.2 Impact

The impact of the recommendations mentioned above can be significant in helping

make positive changes in society, particularly in addressing stigma and improving mental

health awareness and support.

1) Conduct a follow-up study with a larger population: This recommendation can help

strengthen the validity of the initial study and provide a more comprehensive

understanding of the extent of stigma towards people with BPD in a normative

population. It can also help generate more robust evidence that can be used for

advocacy, policymaking, and interventions aimed at reducing stigma and improving

mental health outcomes for individuals with BPD.

2) Increase education of mental health conditions in academic environments: This can

help raise awareness, reduce stigma, and promote early detection and intervention for

mental health issues. Education in academic environments can also foster a supportive

and inclusive culture around mental health, equipping students with knowledge and

skills to take care of their own mental health and support others.

3) Provide training to management, recruitment, and HR in organizations: Training can

contribute to creating a supportive and inclusive work environment. Increased

understanding of mental health conditions, including BPD, can help reduce bias and

promote empathy and effective support for employees who may be struggling with

mental health challenges. It can also help organizations implement appropriate

policies and accommodations for employees with mental health conditions.

4) Provide more accessible mental health first aid training: Having a Mental Health First

Aider can have a positive impact on early detection and intervention of mental health

conditions such as BPD. Having trained mental health first aiders in organisations can

provide a supportive resource for employees who may be experiencing mental health
 41

challenges, including those related to BPD, and can help create a safe and inclusive

work environment where individuals feel supported.

5) Advertise factual and informative information about BPD: This can help raise

awareness and dispel myths and misconceptions. It can also encourage conversations

about mental health, including BPD, and contribute to reducing stigma and increasing

understanding in the wider public.

Overall, these recommendations have the potential to contribute to reducing stigma,

increasing awareness, improving support and interventions, and creating a more inclusive

and supportive environment for individuals with BPD and other mental health conditions.

However, it's important to note that the actual impact would depend on the

implementation and effectiveness of these recommendations in specific contexts and

settings.

7.0 Critical Reflection Statement

This research was conducted under extraordinary circumstances. Due to my own

personal health difficulties, I only had one calendar month to complete the dissertation. I

proactively researched my chosen area using well established sources of information and

planned and organised my time as accurately as possible to ensure that my dissertation was

completed in time. This project helped me develop my qualitative research skills and has

been an enriching process. I have found it particularly interesting interviewing the study

participants and learning the thoughts and feeling of others using my empathy skills.

As a researcher conducting a qualitative approach to evaluate the stigma towards people

with BPD, I engaged in critical self-reflection to ensure that my research is conducted

 42

rigorously, ethically, and without continuing stigma. Here are some critical self-reflections

that I have considered during my research:

1. Reflexivity: Reflexivity is crucial in qualitative research, as it involves examining my

own assumptions, values, and perspectives, and how they may influence the research

process. I actively engage in reflection on my own positionality and acknowledge

how my own background, experiences, and identity may impact the research findings

and interpretations. This allows me to be transparent about my potential biases and to

critically evaluate how they may shape the research outcomes.

2. Power dynamics: I recognize that as a researcher, I hold a position of power in the

research process. This includes the power to shape the research questions, select the

methods, and interpret the findings. It is essential for me to be mindful of the power

dynamics between me as the researcher and individuals who may participate in my

research. I must strive to create a research environment that is respectful, inclusive,

and empowers the voices of those with lived experiences.

3. Intersectionality: Stigma is not experienced in isolation, but often intersects with other

forms of social oppression, such as race, gender, sexual orientation, and

socioeconomic status. It is important for me to consider intersectionality in my

research on stigma towards BPD and acknowledge the unique experiences and

challenges faced by individuals with diverse backgrounds and identities.

4. Ethical considerations: I am mindful of the ethical considerations involved in

conducting research on individuals with BPD. This includes obtaining informed

consent from participants, ensuring confidentiality and privacy, and protecting the

rights and well-being of participants throughout the research process. I also consider

the potential emotional impact of discussing sensitive topics related to BPD and take

appropriate measures to support participants and minimize any potential harm.

 43

5. Participant selection: In qualitative research, participant selection is crucial to ensure

the representation of diverse perspectives and experiences. I reflect on the potential

biases in my participant selection process and strive to include a diverse range of

individuals considering factors such as age, gender, ethnicity and socioeconomic

status. I also acknowledge that recruiting participants may come with unique

challenges, and I take measures to ensure their comfort and well-being throughout the

research process.

6. Reflexive analysis: In qualitative research, data analysis is an iterative and reflexive

process. I critically reflect on my own role and potential biases during the analysis

process and actively seek feedback from peers or other researchers to challenge and

improve my interpretations. I strive to provide a nuanced and contextualized

understanding of the stigma experienced by people with BPD, based on the rich and

diverse narratives shared by participants.

By completing this research project, I have managed to raise awareness to support

something I am extremely passionate about, mental health and more specifically BPD. My

aim was to provide and insight and understanding of stigma towards people with BPD which

I believe I have managed to do in this research project. Completing this dissertation has

helped me refine and increase my psychological skills and also provided me with a strong

understanding of conducting qualitative research. I shall utilise the skills I have gained to

help raise further awareness and hopefully conduct further research in an academic

environment in the future. I have an increased appreciation of qualitative research and feel

that I have seen first-hand how effective a method of research it truly is. I am now more

confident in conducting qualitative research and am eager to continue my studies and conduct

further research in the mental health field in the future.

 44

Overall, I believe critical self-reflection is vital in conducting qualitative research on the

stigma experienced by people with borderline personality disorder. By being aware of my

own biases, engaging in reflexivity, adhering to ethical considerations, being mindful of

participant selection, empowering and representing participants, and engaging in reflexive

analysis, I can strive to conduct research that is rigorous, ethical, and contributes to a deeper

understanding of BPD-related stigma and social change.

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Appendices

Appendix 1: Interview Guide