Borderline Personality Disorder: Bah

 

Primitive mental state-that is what I strongly prefer to say when my students tell me that their patient, or their patient’s mother has “Borderline Personality Disorder.” My reasons are many, which begin with I find this diagnosis misogynistic, given to women who exhibit colorful or spirited emotional responses to stress, thereby imposing a judgment in which emotional reactions are somehow pathological. I accept that women and men, as a general rule, express themselves differently, but to say that a woman who describes dark moments in her feelings a “borderline” is to inhibit the facilitation of emotional expression. Second, I find this diagnosis a way of saying that the doctor does not like the patient, and finds the patient’s emotional experience objectionable. It is as if the doctor perceives the patient in a compassionate way, then the doctor diagnoses Major Depression, but if the doctor starts to feel uncomfortable with a patient, then he/she is more likely to throw the personality disorder label on the patient. Third, the terminology “Borderline Personality Disorder” does not convey the process in which the personality needs help. I prefer the developmental model of personality in which some of us fail to develop, or we develop and then we regress to more primitive expressions of our feelings which often involve rage and bodily and/or property destruction. If we were to use the term “primitive mental state” then we convey a certain hopefulness, that with all states of mind, they are fluid and subject to maturity and emotional growth, whereas “Borderline Personality Disorder” implies a life-long struggle which borders, pun intended, on hopelessness.

My students, taught this diagnostic system, are almost always taken aback by my objection to our language, which shapes our thinking, and hence our interventions. The advantage of a big institution, like UCLA, for example, is that students are exposed to multiple ways of approaching this complicated organ, we refer to as the brain. This seems to give little comfort, when I encourage them to challenge their rock stars. Students, like patients, have a transference to their teachers, and so learning new information, in such an intimate setting, is not an emotionally neutral experience, but rather it is an experience filled with identifications and defensiveness. Therein lies my challenge. I need to work with both the conscious and unconscious aspects of my student’s brain, while at the same time, not go too deeply into their own personal dynamics. Like psychotherapy, this is a delicate dance, which most of the time goes well, but occasionally I need to be mindful, not only the layers in treatment, but the layers in teaching as well.

Borderline? I Don’t Think So…

Primitive mental state, that is what I want to call “Borderline Personality Disorder”. The name is pejorative, misogynistic, and used to describe a patient with a valence of hopelessness. Plus, as per the description above, many of the “characteristics” describe immaturity, and so most “Borderlines” tend to grow out of it. I would say that psychiatry has lost its way, as I often say, but in this case, this diagnosis has been around for many decades and I have always found it objectionable.

Laura, thirty, cannot find a relationship or a career. She lives at home with her parents, despite a graduate education in film. She is constantly breaking up with potential boyfriends, terribly depressed and hopeless, but then continues to find partners who disappoint her and the cycle continues. She has never looked for a job because she feels that a job is “too traditional.” When asked how she imagines being independent, she says “I will figure it out”. Laura is constantly angry. She is angry with her parents for not being “tougher” on her. She is angry with her sister for “not being there for her”. She is angry with her friends for “not including her in all of their plans.”

Is Laura “Borderline?” I would not say that. I would say that Laura is immature. She has failed to grow up and develop independence from her parents and her own power over her world. She has failed, so far, in obtaining a partnership which she experiences as fulfilling. To the extent that she is aware of her failings, she is angry and she turns that anger outwards towards those closest to her. Psychotherapy can help her focus on her need to make her mark in the world; her need to find work and love, as Freud would say. With these forward movements, her anger will subside and she will be “cured” of her personality disorder, which is to say that her developmental arrest would have been addressed, allowing her to grow, develop and thrive in her world. To label Laura a “Borderline” is to cast a long shadow over her future. To say she is exhibiting a “Primitive Mental State” is to describe the current situation, without forecasting her future.

In essence, my forefathers (since they were mostly men in those days) set us up to describe mental states as if we can see the future, when in fact, we are looking at a stunted development which can be set straight. To see the “Primitive Mental State” in developmental terms allows for great hope in the ability to access the genetically determined push towards independence and self-empowerment. To say that the patient is “borderline” is to say that their behavior is so unsavory, few people want to get close. The label matters. My rant continues.

Borderline Rant

 

 

http://en.wikipedia.org/wiki/Borderline_personality_disorder

 

23 years in practice and I still struggle with this diagnosis of a borderline personality disorder. I tell my students that I have never seen one, meaning that what they see, I do not. Brianna, twenty-five, has had multiple suicide attempts. She is the product of an Italian immigrant father and an African-American mother. She complains that she cannot fit in anywhere, because of her mixed heritage, and as a result, she often feels like killing herself. My students, who have seen Brianna, say she is borderline or Asperger’s. I propose that she is lost, searching for meaning in her life. Once again, I find myself using lay terminology to express the desperate feelings that lead to self-injurious thoughts and behaviors, in preference to the jargon in psychiatry, which I find to be unhelpful in terms of thinking about how to help patients like Brianna. Once again, I feel the laziness of using diagnoses like Bipolar, Asperger’s (now Autistic Spectrum), or Borderline, as a way of NOT thinking about the struggles of living in this world. Psychiatric diagnosis, sometimes, skims over the complexity of mental existence, leading to yet another irony, where on the one hand, in the neurobiological world, the brain is seen as complex, but in the clinical world, there is a push towards simplicity. Self-injurious thoughts do not necessarily imply a DSM 5 mental illness, but often implies, psychological pain, which is not an illness, but a symptom of a deeper problem of struggling to latch on to the beauty of the world, and the  beauty of oneself. All of this dispute, my plea to get away from jargon, makes me scared that psychiatry will bury itself. Brianna, and so many people like her, need understanding and listening; they do not need a label. Other mental health professionals (non-MDs), and clergy, understand this, but psychiatry, at least a large part of psychiatry, pushes away from the value of embracing the complexity involved in finding meaning in life. Labeling patients Borderline often embodies this issue. It is as if the label stops the psychiatrist from probing deeper into the personal struggles of Brianna. She is Borderline, implying that she needs medication to control her impulses. I do not have an issue with giving Brianna medication to control her impulses, but I do have a problem if the intervention stops there. Controlling her impulses allows Brianna to become more contemplative, and hence more reflective on what is important to her. Medication in this light, opens the door to an internal journey which is messy and complicated, but ultimately helpful to Brianna becoming an authentic, and hence beautiful human being. I repeat. She is not Borderline. She is lost . So is psychiatry.