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For years, the general public and many in the psychiatric community have viewed mental illness in boys and mental illness in girls in very different ways. To illustrate, Alan E. Fruzzetti, PhD, program director of the 3East Boys Intensive DBT Program, offered a simple test: “If I told you that a student in a classroom was pounding on a desk and being disruptive, would the image of a boy or a girl enter your mind?” he asked. “Or, if I told you that a student in a classroom was upset and incessantly tapping on a desk, would you think it was a boy or a girl?”
Most of us, Fruzzetti said, would imagine the “pounding” student was a boy and the “tapping” student was a girl. And, when observing essentially the same behaviors, many people would describe them very differently, according to gender. Why? Fruzzetti pointed to a number of factors, from societal conditioning to longstanding beliefs concerning “normal” gender behavior, along with other biases to explain why we view boys and girls through different lenses. “The problem is that both boys and girls display ‘non-normative’ behaviors, and our misunderstanding of these behaviors has produced serious consequences for their mental health,” he explained. “Different behaviors are acceptable—or troubling—for different genders, and thus social responses can be very different for boys and girls.”
There are large gaps in the kinds of mental health services available to boys and girls. In general, Fruzzetti explained, a girl who is angry, depressed, or displaying other signs of distress has a better chance of being treated with compassion and understanding—and being referred to counseling and treatment—than a boy. In contrast, boys who show similar behaviors are often punished or ignored completely.
This gap between boys and girls is particularly pronounced in the diagnosis and treatment of borderline personality disorder (BPD). “The percentage of the population with BPD is about the same for men and women, but the condition is likely slightly over-diagnosed in women, and significantly under-diagnosed in men,” Fruzzetti reported. Many studies, he said, have explored the differences between men and women who meet the criteria for BPD, finding that more men with substance abuse disorders are diagnosed with BPD than women, while more females with eating disorders or PTSD are diagnosed with BPD.
“When boys don’t fit social and emotional norms, their behavior can be misinterpreted,” Fruzzetti said, and “bias around gender may have a lot to do with these different diagnoses.” For example, when men display anger, it is more often seen as a sign of antisocial behavior than it is in women, even though women with BPD show more aggression than non-BPD women, and men with BPD show less aggression than non-BPD men. Also, established stereotypes about the nature of masculinity can lead to BPD being misdiagnosed or missed altogether. “In general, boys tend to have fewer social and emotional skills than girls, and this is often misunderstood and incorrectly attributed to a lack of motivation or to them having bad character,” Fruzzetti said.
Because of misdiagnosis and under-diagnosis, many boys with BPD do not receive any treatment, receive the wrong treatment, or worse, end up in prison. Fruzzetti said that about 20% of males in the criminal justice system actually have BPD. “Overall, our system is not set up to help men with BPD, but the prison system in particular does not provide proper treatment,” he said. “In prison, biases and stigma about mental illness are intensified, and ‘treatment’ is usually based on punishment, not compassion.”
To address the issues surrounding boys and BPD, Fruzzetti and his colleagues at McLean Hospital created a new program early this year that focuses exclusively on treating boys living with BPD. An outgrowth of the hospital’s 3East adolescent dialectical behavior therapy programs, Fruzzetti and his team work with up to six boys at a time, teaching psychological and social skills to regulate emotions, improve self-awareness, increase tolerance of stress, and build meaningful and stable relationships. Although the program is only a few months old, Fruzzetti is confident that the program is bringing the right care to boys with BPD.
“We’ve seen positive results,” he said. “We’re very optimistic about the future of the program.”