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Borderline Personality Disorder: Patriarchal Boundaries of Sanity, Self, and Sex

James Higginbotham
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NOT FOR PUBLICATION Borderline Personality Disorder: Patriarchal Boundaries of Sanity, Self, and Sex by James I. Higginbotham --bor'der·line n. 1. A line that establishes or marks a border. 2. An indefinite area intermediate between two qualities or conditions. --bor'der·line adj. 1.a. Verging on a given quality or condition. b. Of a questionable nature or quality; dubious. 2.a. Psychology. Relating to any phenomenon that is intermediate between two groups and not clearly categorized in either group. b. Relating to a condition characterized by a pattern of instability in mood, interpersonal relations, and self-image and manifested by self-destructive, manipulative, and inconsistent behavior. (American Heritage Dictionary) INTRODUCTION The term “borderline” is a metaphor for a perceived boundary between two concepts. In the psychiatric world, borderline refers to a personality type who exists in the “no man’s land” between sane and insane. I use sexist language intentionally, because this diagnosis is overwhelmingly applied to women; officially (APA, 1994), ¾ of those diagnosed as borderline are female. In my own professional experience, the ratio is greater than 5 to 1, even though studies (e.g., Trull, 1990) suggest that these borderline characteristics are more numerous among non-clinical men than similar women. Such disparity suggests that this “mental disorder” is a focal point for hidden assumptions and contradictions within psychiatric thought. The best method of interpreting this fabled persona is through an examination of the discourse that inscribes her in this militarized zone with a number, 301.83, and a designation, Borderline Personality Disorder. A review of the authoritative “speech acts” of the psychiatric community is an appropriate starting point for a public debate (Benhabib, 1992). Since no voice should be privileged as a given, then the official rhetoric of the psychiatric system should be scrutinized for its metaphysical and ethical assumptions (Browning, 1987). This analysis of the diagnostic criteria of BPD requires a hermeneutic of suspicion regarding the discourse of psychiatry, specifically the Diagnostic and Statistical Manual of Mental Disorders (DSMTM). The question is whether Axis by II1 of the DSM, which classifies disorders of personality, is largely speculative and ultimately political in nature. I believe these diagnostic categories not only reflect a patriarchal social order, they’ve often been used as instruments of hegemony and have little therapeutic value. As a pastoral counselor I’m also troubled that the worldview reflected in personality disorders is incompatible with Judeo-Christian thought. Belief in a Creator implies the value of all persons and a desire to understand the other, but a psychiatric diagnosis of borderline seems much less an attempt to appreciate a person’s character, than to pigeonhole. Given this concern to protect the integrity and individuality of persons who have been given this label, I will not use “borderline” as a pronoun, and not present any case studies. It is my thesis that the issue of BPD embodies central questions of sanity, gender, and self, and their relation to Western society. In literature, the metaphor of a border often references an entire culture, which is feared and demonized, like the U.S. obsession with the Mexican border (Wirth-Cauchon, 1993). I propose to show that this diagnosis is indicative of patriarchal circumscription of the boundaries of gender and madness and, more directly, the cultural borders that the psychological world is designated to legislate. In other words, psychiatry helps define the border of normality, and thus indirectly shapes norms of gender and morality. In the process of drawing these lines, women are accused of crossing boundaries like inappropriate anger, sexual promiscuity, and uncomfortable relating, and these are interpreted as signs of mental pathology. So the thrust of this paper is that, like all disputed boundaries, borderline is a site of controversy, not just about gender and madness, but also the limits of psychiatry. 1 The DSM is a multiaxial diagnostic tool. PD’s are identified on Axis II, but the more familiar clinical conditions such as affective, anxiety, substance abuse, and adjustment disorders are classified as Axis I disorders. 2 AT THE BOUNDARIES OF ONE SELF The first three criteria of BPD (see Appendix) raise the critical questions of what is a self and what is an appropriate relation between self and others. The terminology includes a mixture of psychodynamic or post-Freudian language (“idealization,” “devaluation,” “self-image”), traditional medical-ese descriptors (“intense,” “markedly,” “persistently,” “extremes”), and ambiguous concepts and adjectives (“frantic efforts,” “abandonment,” “unstable,” “identity disturbance”) that invite conflicting interpretations, if not a projection of the clinician’s fantasies and expression of entrenched prejudice. Inconsistency in vocabulary and theoretical orientation is a core problem regarding the normative character of the DSM. For example, many of the ethical assumptions ensconced in Freudian theories are present. Medical language partially masks the values evident in these three criteria; first, a person should have composure, even in the face of a crisis like abandonment; second, a unified, stable self-image is normative; and third, a consistent view of others, based on non-emotive (rational) processes, is ideal. These may well be fairly-well accepted mores in our culture, but given the prescriptive character of the DSM, such norms must be adduced up front. The concept of an independent, static, and unified self is a standard against which patients are measured in this discourse. However, evolutionary and social psychologists, feminists, and others have asserted that persons may be better understood through the affiliations in which they have been involved, than by the traditional view of autonomy and differentiation. Let me offer a couple of examples of these theories. Feminist theologian Catherine Keller (1986) has cogently argued that a young child is 3 inherently relational and that patriarchal societal forces encourage the belief that separate identity is a primary goal of human development. Keller and other process-thinkers also advance the primacy of relatedness one step further, proposing a notion of self that is constantly changing, in flux with the experiences and people to whom one relates. In this theory, autonomy is not fundamental, because one is connected with everything over against which one might identify oneself. Human identity is process-oriented and fluid, not singular and fixed. Another argument against the model of self that is normative in the DSM arises from renowned psychologist Nancy Chodorow’s (1989) critique of the Freudian view of human development. Chodorow demonstrates that women’s ego boundaries are more permeable due to the primary care and socialization of girls by women. Thus, the cognitive style implied in the diagnostic language might also be due to culturally constructed gender incongruities. Psychologist Dana Becker (1997) applies a similar analysis to the borderline classification that is more disturbing. Becker contends that like Snow White, women are socialized through mirrored appraisals of others to have identities that appear fractured. Tragically, girls’ identities often shatter under the pressures of adolescence into the condition that receives the borderline label. Becker (p. 108) provides a compelling argument that the twin phenomena of “female sexualization and devaluation” are dominant forces creating a culture of invalidation: “Invalidating environments can engender the development of a false self because, in these environments, an individual is encouraged to bring into play only those aspects of her inner experience that fit the inner experience of another.” These first three criteria of BPD give testimony to male definitions of the normative self. 4 There is evidence that what is pathologized in the DSM is at least typical of women’s socialization, if not potentially more true of human relations in general. The view of a healthy person as autonomous, always rational, and having very firmly-defined relations with others has been challenged on many sides as at least being untrue of women. Some argue that relationality is feared by men because it diminishes the power of masculinity; is this why the porous boundaries of BPD is pathologized? I am not suggesting that there should be no limits to the fluidity of self and relations; people need boundaries to develop and function. Clearly, though, a person with a rigid view of self and others will function much better in this patriarchally-defined society than those on the other end of the spectrum who are probably more commonly termed mentally ill. THE LINE BETWEEN HATE AND FEAR The 4th, 6th and 8th criteria of BPD point to the misogynistic nature of this diagnosis. When these criteria are added together, they create a caricature of a “bitch,” that dangerous, unpredictable woman whom men fear and must control. A milder version these “symptoms” can be seen in the proposed Premenstrual Dysphoric Disorder (DSM-IV, p. 715ff), an exclusively female and highly criticized diagnosis. Criticism regarding the comparison of PMS and uncontrollable women is so obvious that I only note the persistent history of these oppressive concepts (e.g., Chesler, 1972; Noddings, 1989; and Ussher, 1992). Evidence of sexism is unmistakable in the language here. The proposed PMS disorder is the only other adult diagnosis in which inappropriate anger is a criterion. For example, Antisocial PD (largely attributed to men) uses the words irritability and aggressiveness as standards, but only if enacted through assault. Only oppositional defiant children are also 5 described as have difficulty controlling their anger. When insolent kids and women are the only ones pathologized for throwing temper tantrums as opposed to violent behavior, then the discourse is suspect. The acclaimed movie, Girl, Interrupted is a dramatic first-person portrayal of being labeled borderline. Diagnosed as an adolescent, Susanna Kaysen was shuffled in and out of treatment facilities for a decade, often against her will. Her profound cynicism is understandable when one examines the symptomatic language under which Kaysen (1993, p.148) was diagnosed the 1960's. Earlier versions of the DSM included “shopping sprees,” “casual sex,” and “promiscuity” as symptomatic. Kaysen (p. 158) wonders how many girls a 17-year-old boy “would have to screw” to be judged promiscuous, as she was for sleeping with her one boyfriend and getting caught for the lack of a private location. Kaysen’s (p. 156) cry “What would have been an appropriate level of intensity for my anger at feeling shut out of life?” joins a chorus of voices which echo against unmoved patriarchy and the mental health profession. These are not questions of whining shrews; there is much evidence of a misogynistic mental health culture. For example, psychiatrist Gerald Schoenewolf’s 1991 book, The Art of Hating argues that destructive hate is the chief problem of human existence. Schoenewolf identifies cultural depictions for several types of hate. For the Borderline type, he provides a list of seven female examples especially the famous movie Fatal Attraction [also Zola’s Nana, Souther’s Candy, Carmen, Salome, and the female stars in Blue Angel, Pretty Poison], and only one male possibility, Dr. Jekyll and Mr. Hyde, is really drug-induced. I emphasize Fatal Attraction, since it is often mentioned as prototypical of BPD, and suggests the image of a 6 powerful and destructive female figure whose violent rage victimizes men. Schoenewolf (p. 48) unknowingly supports this stereotype in his clinical description: “Borderlines are extremely touchy individuals and it is hard to know quite what is going to set them off or how to relate to them.” A critical question arises: how much of this “dangerous anger” is in the perception of the clinician? In psychiatric thought, rage is a sign of a breakdown in ego control that connotes an unstable person. Yet, perceived resistance in the clinical relationship often is equated with such out-of-control anger, too. Critics (Wirth-Cauchon and Greenspan, 1983) claim that since resistance is a potential threat to the therapist’s authority, it makes clinicians feel helpless and want to flee from the patient. Thus, women are accused of resistance and inappropriate anger, because of a threat to the power of the counselor. This was Susanna Kaysen’s experience when she reflected on her treatment by numerous male psychiatrists. Feminists (Greenspan) have long critiqued traditional psychology, asserting that actions by many women considered resistant are, instead, refusals to participate in the power dynamics of the therapeutic relationship or a rejection of patriarchal domination, which they have experienced all too often. Unfortunately, when anger is pathologized appropriate cries of injustice may not be heard. Anger becomes outside the bounds of women’s discourse, and silences them in one more manner. Therefore, anger is kept from being the empowering emotion that it can be, especially for those who have undergone oppression (cf., Saussy & Clarke, 1996 and Greider, 1996). In my work with numerous women who might fit the description of this disorder, anger often has been experienced as an emotion in which they felt the most alive, filling an emptiness that seemed 7 present, and thus therapeutic. BORDERING ON ILLNESSES The fifth, sixth, and seventh criteria of BPD surface diagnostic questions. Perhaps many who are diagnosed with this PD actually should be understood as coping with a mental health concern like depression, which would connote less shame and open up other possibilities for treatment. The ninth symptom, dissociation, adds the category of Posttraumatic Stress Disorder (PTSD) as a potential reason why so many women receive this designation. Although confusion between categories is a problem throughout the DSM, there are indications that BPD is less tenable than most diagnoses. Evidence of heterogeneity can be found in the history of this classification. I contend that since “borderline” serves as a metaphor for the boundary between two enigmatic concepts – sanity and madness – the term has become a collection of disparate formulations brought together into an artificial unity in the DSM. At the turn of this century, use of the term “borderline” usually referred to symptoms that would be classified as Manic-Depressive today. In classical psychoanalytic thought, it was conceived as the territory between neurosis and psychosis, and in neo-Freudian theories, related to conception of the self and the not-self. One chronicle of this history (Wirth-Cauchon) documents that analytic, neo-Freudian, and other uses of the borderline term were merged into a single character type through the political process of the DSM. I would even argue that the inclusion of several PD’s – borderline, narcissistic, and histrionic – was, at least, partially a trade off for the elimination of the neurosis concept. Supporting these hypotheses is a recent, curiously honest revelation by Theodore Millon 8 (1996), the leading figure in the DSM’s work on PD’s. Millon’s final memo as the senior author of the DSM-III committee, which included the BPD diagnosis for the first time, argued for almost any other term than “borderline” as the nomenclature for this population. He (p. 659) said “borderline” designates a “level of severity” more than a description of a disorder. Millon’s memo nearly admits that “borderline” is what I would call a wastebasket of ideas organized around a term. Notably, when first introduced, BPD became (and still is) the most commonly diagnosed personality disorder. Thus, in a nearly arbitrary manner, the discourse of borderline has evolved from a non-category – a territory between disorders – to a popular discrete entity. One possible genesis for some features of BPD is trauma. It has been observed that in a large percentage of cases the symptomology and experiences of persons identified as BPD coincide with the recovery from early trauma and should warrant a diagnosis of PTSD (Becker and Brown & Ballou, 1992). Research has found that the PTSD label is often not applied, even when it is more appropriate than BPD. In a study involving hundreds of clinicians, Dana Becker found that if a patient is identified as a woman, male clinicians are significantly more like to diagnose BPD than PTSD when given a hypothetical case containing equal symptoms of each. Becker does not comment on the particularly dubious nature of this taxonomic issue: a PD is not to be diagnosed if an Axis I disorder like PTSD could better account for the symptoms. Similarly, a significant amount of comorbidity or clinical overlap between depression and BPD has been observed. Studies have raised the possibility that this collection of symptoms is a type of depression that primarily impacts women with certain predispositions. Compounding this connection is a recent national report on women’s depression (McGrath, et al., 1990) which notes 9 that possibly a majority of women who suffer from major depression have been victims of sexual assault or other severe trauma at some point in their lives. So there is both empirical and theoretical basis for an argument that in many cases BPD should be understood as depression, possibly involving distortions in self-image due to the social construction of gender identity. Threatening the diagnosis in a very different manner, BPD is hypothesized to be delayed development. One of the most comprehensive studies of hospitalized patients with a BPD diagnosis (Stone, 1990) concludes that two-thirds will “get better” regardless of treatment after the age of 30. If improvement occurs simply with maturity, then is the discourse of BPD a judgment of deviance given women by a patriarchal society that resists assertiveness and encourages passivity in young women? Such questions raise serious concern regarding the usefulness of BPD. Heterogeneity and comorbidity are problems for every diagnostic category, but there is strong evidence that PD’s in general and BPD in particular are more prone to these difficulties. WHAT’S IN A NAME? Having examined the vocabulary of the DSM, I briefly want to turn to social and historical factors that have shaped the discourse. Many (Becker, Brown & Ballou, Chesler, Ehrenreich & English, Greenspan, and Ussher) have argued that women’s high rate of mental illness is a product of their male-defined roles as second class citizens and their mistreatment or stereotyping by a male-dominated and possibly misogynistic psychiatric profession. Certainly increased exposure to stressful life events – such as mothering, greater poverty, and a host of subtle and overt oppressions – is likely to be a factor. However, I am also asserting that normality 10 has been defined such that women’s ways of acting, thinking, and especially relating are considered closer to the line of what is madness than the “normal” male ethos. Both gender and sanity are largely social constructions designed to order culture and control forces that are constitutive to existence, but are not fully understandable. The phrase “a normal person” seems self-evident, but everyone is blind to their quirks, and normal is exceedingly difficult to define. Moreover, these issues are historically formed, and have changed dramatically (cf., Scheff, 1984 and Ussher). Legal and medical definitions are now at the forefront, and religious language has faded into etymology. Women are no longer called witches or demon-possessed, they are marginalized with labels that have technical sounding symptomology and fancy hypotheses about etiology. Given such a history, we must consider the claims of the infamous psychiatrist, Thomas Szasz (1961, p.292; italics orig.), who criticizes the mental health profession as an insidious language-based game, in which “the psychiatrist as manipulator of human material punishes, coerces, or otherwise influences people to induce them to play, or cease to play, certain games.” If the game is about gender, then perhaps such criticism is warranted with regard to BPD. Other scholars wonder if some behavior described within the BPD can be viewed as appropriate adaptation to women’s marginalization. Psychoanalyst Andrew Samuels (1988) observes that many women suffer tremendously from a circumscribed interpretation of what it means to be female. Women are encouraged to be non-aggressive, selfless creatures who relate to everyone, but receive little affirmation in return. Samuels asserts, “Borderline-personality disorder may be regarded as a kind of protest of this requirement.” There is evidence of such 11 adaptation in research (Chin 1994) that shows how well-functioning women who are defined by more than one culture alter their behaviors according to the different value settings. For example, an Asian-American woman might be deferent with an authority figure like her husband, while confrontative and challenging at Euro-dominated workplace. Such behavior can be easily pathologized as splitting, but it is clearly adaptive for such multiply-defined women. Much of this involves labels (cf., Scheff), a necessary, but potentially destructive force within any discourse. Society labels certain qualities as female, others as abnormal, and some are called self-destructive. The pernicious thing about labels is the manner in which they tend to coalesce into a larger stereotype. So, like histrionic, and dependent “characters,” there is a borderline persona, born largely out of psychodynamic writings. In the clinic, the diagnosis of "borderline" often creates reactions similar to a contagious disease: “I don’t want to have anything to do with that client.” Even well-meaning pastoral counselors (e.g., Martin, 1995) pigeonhole BPD’s as manipulative and dangerous. When a name creates the unintentional appraisal of a therapeutic pariah, the discourse is suspect. Nevertheless, the nature of sanity and normality is critical to human existence, and needs to be defined. Care must be used, especially since mental illness is not a bodily disease in which an organ ceases to function, rather socially aberrant behaviors which often have unknown etiology. Such concern is particularly relevant to the label of a PD, which is designed to identify maladaptive characterological styles of behavior. Unfortunately, this is essentially the immorality of an individual according to a social definition of what is good for a person and society. At this point, I feel trapped between different discourses and ways of making sense of 12 human nature. As a counselor I have seen patterns of behavior that seem consistent, which appear to contribute to the painful stories I hear. I identify similarities that fit the PD categories I am calling into question. I am not sure how much of what I am seeing is due to my socialization, since I can’t step outside my social identity as a clinician. My suspicious side questions the legitimacy of these DSM categories, because they appear arbitrary. My religious convictions include a basic belief in the goodness of all persons, implying that since humans do not randomly organize their experience, there must be some positive meaning to these patterns, not just maladaptability. Capping my confusion is the realization that mental illness is, at best, a fuzzy concept involving social judgment and limited empirical evidence (cf., Lilienfeld & Marino, 1995). I have to agree with psychiatrist Andrew Samuels (p. 182), “The borderline speaks to us so deeply because in it we test the limits of sanity and madness.” Borders are critical to discourse about human nature and relations. But are there ever clear boundaries in human psychology, or only border areas? So maybe BPD exists as a protection for those of us within mental health, from forces of the mind that we know to be uncontrollable, but don’t want to face within ourselves. Surprisingly, support for this possibility is in the DSM-IV (p. 651) itself, in its description of BPD’s most dramatic symptom, self-mutilation, as “expiating the individual’s sense of evil.” Here the DSM directly raises the ugly head of immorality, of course attributing it to the borderline’s sense of self. In the end, this discussion is really about the nature of evil. Throughout Western history, women in general, and types of women in particular, have been placed in a 13 position of blame or marginalized as crazy or evil to protect the dominant viewpoint. If only certain people are on the border of madness and evil, then those who make the rules have less reason to consider their own insanity or the immorality of their rules. Maybe it is not so cynical to believe, then, that the game of life can be understood as an attempt to write the instructions so as to define the dominant group as the “good winners,” without letting the “losers” know that the game was rigged. Thus, I have examined the rules of diagnosis. Within them are suggestions of arbitrariness and oppression, as well as ambiguity. If, as research indicates, that among those most cruelly oppressed for decades, some tendencies to what is called pathology becomes ingrained at the genetic level then changes to society are more profoundly needed to try to reverse the effects of centuries of misogyny and other forms of subjugation. Otherwise, persons like those labeled as having personality disorders become the scapegoat for social evil. Blaming the victim is an age- old tradition among dominant powers, which will continue until there is greater appreciation for the interconnection of personal and social difficulties, and a resulting change in the labels which are used for those who suffer the most. If all that I have implied is true, then all of us have a little “borderline” within us. To believe otherwise, I think, only encourages oppression. We must either join those who have been relegated to the borders of our culture or eliminate the boundaries entirely. Inclusion of the “marginalized” voices into the discourse is necessary. Therefore, this paper has been a preliminary attempt to examine the language and method by which certain persons are marginalized and oppressed, and, in a sense, cross the boundaries which supposedly separate. 14 This is a small step in a much larger project of identifying the means by which our society normalizes certain behaviors and beliefs through the power of our cultural institutions. Such an analysis is necessary, since in my opinion, a psychologically astute, theologically informed dialogue will be more attentive to the unnecessary borders and boundaries which characterize most discussions, hopefully leading to a more open and just conversation about what is or should be normal. Appendix Diagnostic criteria for 301.83 Borderline Personality Disorder A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1) frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self- mutilating behavior covered in Criterion 5 2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation 3) identity disturbance: markedly and persistently unstable self-image or sense of self 4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self- mutilating behavior covered in Criterion 5 5) recurrent suicidal behavior, gestures, or threats, or self mutilating behavior 6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and rarely more than a few days) 7) chronic feelings of emptiness 8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 9) transient, stress-related paranoid ideation or severe dissociative symptoms 15 REFERENCES American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders, Fourth Edition. Washington, DC: Author. Becker, D. (1997). Through the looking glass: women and borderline personality disorder. Boulder, CO: Westview Press. Benhabib, S. (1992). Situating the self: Gender, community and postmodernism in contemporary ethics. New York: Routledge. 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Doctoral dissertation, Department of sociology, Boston College, 1993. 18