About a month ago I read this piece, "An Emotional Hair Trigger, Often Misread" by Jane Brody in the New York Times. I have been meaning ever since to write about it, but only just got around to it. I was going to write about the limitations of DBT, which Brody extolls, but instead I want to report something I wrote a couple of years ago.
If you read here very often, you know I take issue with a lot of psychodiagnosis so it should come as no surprise that I have a lot of thoughts on this issue -- about the DSM IV, about the brain vs mind split in mental health and about application of the diagnosis of Borderline Personality Disorder.
When I was writing my dissertation -- about Medea and Betrayal -- I read a lot of recent literature on borderlines, as Medea is often pointed to as an example of one. It is very tempting to assign a psychiatric diagnosis to Medea, an interesting endeavor given that she is a character of myth and not a human. In a society relatively tolerant of eccentricity, madness or psychopathology usually becomes of issue only when the person somehow offends or frightens others or breaks the law. The hermit who lives quietly alone, the person with the driven need to record every moment of life in journals, the cat lady with her dozens of cats, the dog man who walks like a Pied Piper of canines as he goes about are all free to live unfettered by diagnoses and encounters with the medico-legal establishment so long as they do not call too much attention to themselves by threatening others, endangering others, giving cause for concern among others, violating public health or other zoning laws. As soon as they do cross one of those lines, however, speculation begins about what kind of mental disorder they suffer from, as we do not have much tolerance for behavior too far off from consensus about what is normal and thus “right”.
Certainly, we can see in Medea signs and symptoms of disorder. We know the Greeks consider her an outsider, from beyond the borders. Medea, the foreigner, the outsider from beyond the borders of the well-ordered Greek world could well be considered Medea the borderline in the modern parlance of the neatly ordered world of psycho-diagnosis. Consider this Jungian description of the borderline personality:
"The borderline person corrals the ecstasy of madness—not completely crazy, not incapable of making a point or decision, not dead. Some of the features of the borderline-personality organization unwittingly reveal the presence of ecstasy: intense affect, sometimes with depersonalization; impulsive behavior, sometimes directed against the self; brief psychotic experiences; disturbed personal relationships, sometimes exceedingly intimate and sometimes distant." (Andrew Samuels, 1988)
Borders and boundaries are devices we use to order the world. We make lines on a map and then find comfort in knowing that this is where our country ends and theirs begins. But boundaries are less lines than they are areas. Is there a clear line where the land ends and the sea begins? No, instead, we have wetlands that are neither wholly land nor sea, an area in-between. We might want to consider then, that there is an area of personality, present in all of us, which is between what we call sanity and madness, a borderline area.
While Medea does exhibit what we might consider borderline traits, the diagnosis itself poses problems. Where once hysteria was the diagnosis most frequently applied to problem women, today it is borderline personality disorder, which is applied to women about seven times more often than to men.
It would be nice to imagine that there were some scientific way to determine diagnosis. Absent biological or chemical tests to establish diagnoses, we fall back on consensus reality and struggle with the unevenness of such a standard. We look to mental health professionals to be in touch with society’s understanding of people and relationships between them, of relations between emotions and the self, and on local custom and ways of perceiving experiences. One outgrowth of this approach is the DSM IV – an attempt to develop, by consensus, descriptions of all disorders thought to be reflective of mental illness of one kind or another. Categories have been expanded and elaborated in the years since the first edition was published; yet, all but the rarest of categories still depends on the subjective judgment of the examiner. Local custom, training of the examiner, examiner biases, insurance coverage, perceived stigma carried by various diagnoses, and funding sources can all influence the diagnosis made as much as the behavior and history of the patient.
That such factors as funding sources and examiner bias influence diagnosis goes against the image of the medical model as scientific. However, subjective and external factors often matter more than the symptoms displayed. In private practice, the fact that medical and insurance records cannot be guaranteed to be private, the tendency is to choose the least stigmatizing diagnosis possible.
Occasionally a professional might apply a more serious diagnosis to someone they find irritating, in an unconscious attempt at retaliation. Or a facility has beds for patients with one kind of diagnosis but not another, so the effort is made to fit the patient where the space is. Or health insurance severely limits coverage for treatment for minor disorders but is more generous for ones that are more serious, resulting in the push to gain coverage, not strive for accuracy in diagnosis. All of these disturbances, in what we might like to believe is an orderly and scientifically based process, reflect variations in the consensus reality and its deviance from the ideal.
Research on bias in diagnosis suggests that one factor operating in the application of the diagnosis of borderline personality disorder to so many women is what behavior is regarded as “normal” for a woman. One of the features of BPD is aggression, which is viewed with suspicion when displayed by women. It has also been noted that BPD is most frequently applied to women under 40 and to patients that therapists seem not to like. The patient suffering from PTSD (Post Traumatic Stress Disorder) is viewed sympathetically and as the “good” patient, while the patient with BPD, with her anger, aggression and resistance, is the “bad” patient. The criteria for the BPD diagnosis are so fluid that one researcher found 93 ways the criteria could be combined and reach a diagnosis of BPD (Stone, 1990). “In fact, borderline has become the most pejorative of all personality labels, and it is now little more than shorthand for a difficult, angry female client certain to give the therapist countertransferential headaches”(Becker, 2000)
Nearly sixty years ago, Jung was expressing doubts about the value of establishing a diagnosis:
It is generally assumed in medical circles that the examination of a patient should lead to the diagnosis of his illness, so far as this is possible at all, and that with the establishment of the diagnosis an important decision has been arrived at as regards prognosis and therapy. Psychotherapy forms a startling exception to this rule: the diagnosis is a highly irrelevant affair since, apart from affixing a more or less lucky label to a neurotic condition, nothing is gained by it, least of all as regards prognosis and therapy. (Jung, CW, v16)
To diagnose Medea as a borderline, then, is to distance her from ourselves in much the same way the Greeks did by considering her a foreigner, an outsider, a barbarian. If we can see her as Other and not like ourselves, then we can ignore her presence in any of us. What is a borderline after all but a barbarian in modern dress?
Note: Contact me for complete bibliographic references mentioned in this post.