Helping Her Children Transcend the Intense, Unpredictable, and Volatile Relationship: This book, by Christine Ann Lawson, prompted my thinking when it appeared on another behavioral health practitioner‘s best-of-2007 list. In my own career, grappling with the borderline concept has been a crucial and controversial struggle. I am convinced that the borderline personality structure is a pervasive condition of our time and a hidden cause of much suffering. Ironically, there is a taboo more powerful than nearly any other against discussing it openly in mental health fields. This is because diagnosing someone with the disorder has come to be seen as pejorative and clinically useless. One esteemed American psychiatrist gave a talk to new trainees that was all the rage on the grand rounds circuits for awhile, titled something like “The Beginning of Wisdom: Stop Diagnosing Your Patients as Borderline.” I emphatically disagree, and give the name to the thing whenever I see it, often met with embarrassed silence from colleagues. I will not say they are always merely politically correct and wrong to be uncomfortable, but that is often the case.

A recurrent theme here in FmH, it is true, is the damage that incorrect diagnosis can cause, but let us not throw the baby out with the bathwater. The reason to be apprehensive when diagnosing someone with this seemingly pejorative term is that it is often done in a knee-jerk fashion, based only on our feeling averse or hateful toward a patient who paralyzes us with their neediness, offends us with their manipulativeness, and stings us with their rage. All of these are attributes of the borderline, and in the craft of mental health we must use ourselves as a diagnostic instrument and our reactions to people as evidence about them… but only if we are clear about what it is that they bring to an interaction and what it is that we bring. If we diagnose only on the basis of our gut-level reactions to a patient, we are always vulnerable to the possibility that our slips are showing — that we have revealed only our prejudices and foibles as human beings rather than using our best interpersonal skills as clinicians. We do the latter when we remember to diagnose and formulate our patients in a responsible and systematic way, employing but also transcending our gut-reactions.

Here are diagnostic criteria for the boderline personality disorder, from the ‘bible’ of psychiatric diagnostics, the DSM-IV of the American Psychiatric Association:

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 of 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 behaviors, 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 only 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

So why is the borderline concept important? Patients only come to our attention, and get diagnosed with the disorder, when their pathology is dramatically disturbing to themselves or those around them (usually when criterion 5, self-destructiveness, manifests itself). Modern psychiatric diagnostics are descriptive; they depend on observation of outward manifestations and behaviors, i.e. symptoms. There is a deeper, classical tradition in psychology and psychiatry of formulation, i.e. using the outward manifestations to understand a person’s inward dynamics, the forces that make them do business with the world as they do, the construction of their selves. The diagnostic criteria are only the outward manifestations of a core, damaged, way of being and interacting.

I am convinced that many are walking around with damaged selves in the manner the borderline concept gets at, and that that damage is intimately related to the conditions of modern life which facilitate exploitative, unempathic relationships between people — the erosion of personal freedom, the refinement of authoritarian control by the political and corporate forces dominating us, the atomization of family and community, the loss of contact with our personal and cultural heritages as well as our connection with the natural world and our biological selves, the lost arts of forgiveness and apology in modern life. I am convinced that the borderline way of being is at the root of the self-perpetuating cycle through which damage is done to children by narcissistic childrearing; that children raised that way, in turn, raise their own children in a similar way. This is a central means of understanding and explaining the pervasive and inexorable way in which the victim becomes the perpetrator and the crippling of the capacity for mutuality and empathy in modern relationships. The borderline construction of the self, conceptualized in this broader way, is in many ways at the root of modern violence. The brilliant but largely neglected psychological writer, Alice Miller, campaigned against the damage done by broken childrearing practices in a series of books several decades ago, epitomizing our understanding of these processes. Crucially, she recognized our failure to address these issues as a core betrayal of our children. Similarly, I recognize the political correctness that makes us reluctant to use the borderline concept a core betrayal of our patients.

There are additional reasons the borderline personality disorder diagnosis has been seen as inappropriate and politically incorrect. First, it is particularly susceptible to what we call “medical student syndrome”, in which an inexperienced or fledgling clinician reading a list of diagnostic criteria for a condition easily sees the disorder in themselves or those near and dear to them. Subjectivity needs to be tempered with sophistication to make this call responsibly and accurately. Indeed, the core narcissism of our society damages all our selves, so that there is something there to recognize. But it is complicated to understand the implications and subtleties of the borderline formulation.

Also, the borderline notion as commonly employed is gender-biased, rarely applied to men. It is important to recognize that the effects of narcissistic damage in raising boys manifests differently but no less profoundly. Formulating rather than diagnosing (understanding the inward construction of the self rather than how many descriptive criteria a patient meets) can help us to help our male patients as well.

Taking the effort to help my patients understand the borderline concept would in fact be little more than pejorative if it merely condemned them to going through life with a damaged self. Modern psychiatric medicine, focused almost exclusively on biological factors and quick fixes through pharmacology, offers temporary symptom amelioration at best to someone who is living with the implications of a borderline personality structure. I am not going to make this essay a treatise on borderline treatment, but suffice it to say that many of us who still understand the value of psychodynamic formulation and of healing patients through entering into longer-term instrumental relationships with them, talking with them, know that, with a concerted, informed and careful treatment approach, the borderline state is remediable. It is clear that there is decreasing support for this effort both from within the current paradigm of mental health care and, certainly, from the insurance carriers who manage care delivery through bestowing and withholding reimbursement in accordance with unfair and ill-informed notions of what is worth paying for. To my way of thinking, it is centrally important to my patients to help them to understand and forgive what was done to them and empower them to govern their own behavior differently. And centrally important to empower the current generation of therapists and social critics to continue to subvert the dominant paradigm.