In popular media, borderline personality disorder has become linked in particular to beautiful, unstable, and ultimately dangerous white women, most famously Glenn Close’s character in the 1987 movie Fatal Attraction. As a diagnosis, borderline personality disorder went through various iterations before being declared a personality disorder enshrined in the DSM-III in 1980. Psychiatrists described borderline personality disorder, or BPD, in broad terms, with symptoms including intense emotions, fear of abandonment, instability in relationships, impulsivity, distorted self-image, uncontrolled anger, and dissociation. The diagnosis is very commonly used – more than half of those hospitalized with mental illness have been diagnosed with BPD. But another statistic about BPD is more revealing: between 70 and 77 percent of all people diagnosed with BPD are women. BPD is a troubled and troubling diagnosis, one that’s been criticized and theorized and analyzed by feminists, disability scholars, and so-called “borderlines” themselves. In this episode of our ‘borders’ series, we explore the complicated history of a different kind of border: borderline personality disorder.
Transcript for Gender, Psychiatry, and Borderline Personality Disorder
Researched and written by Sarah Handley-Cousins, PhD
Content warning: This episode discusses suicide and self-harm. If that’s something you’re sensitive to, you might want to skip this one or listen with care.
Sarah: Susanna Kaysen’s memoir of her time as a patient at McLean Hospital, Girl, Interrupted, starts with a meditation on how she “crossed over” into madness: “It is easy to slip into a parallel universe. There are so many of them: worlds of the insane, the criminal, the crippled, the dying, perhaps of the dead as well. These worlds exist alongside this world and resemble it, but are not in it.”
Elizabeth: Kaysen explains that for some people, that ‘crossing over’ happens suddenly. Her roommate at McLean, “came in swiftly and totally,” when a “tidal wave of blackness broke over her head. The entire world was obliterated for a few minutes.” But, Kaysen says, “most people pass over incrementally, making a series of perforations in the membrane between here and there until an opening exists. And who can resist an opening?”[1]
Sarah: Twenty five years after her hospitalization, Kaysen hired a lawyer to help her get access to her medical records from McLean. In them, she discovered for the first time that she had been diagnosed with borderline personality disorder, a diagnosis that went through various iterations before being declared a personality disorder enshrined in the DSM-III in 1980. Psychiatrists described borderline personality disorder, or BPD, in fairly broad terms, with symptoms including intense emotions, fear of abandonment, instability in relationships, impulsivity, distorted self-image, uncontrolled anger, and dissociation. The diagnosis is very commonly used – more than half of those hospitalized with mental illness have been diagnosed with BPD.[2] But another statistic about BPD is more revealing: between 70 and 77 percent of all people diagnosed with BPD are women.[3]
Elizabeth: And in popular media, BPD has become linked in particular to beautiful, unstable, and ultimately dangerous white women. The most famous example is Glenn Close’s character in the 1987 movie Fatal Attraction. In the movie, Michael Douglas’s character, Dan, has what he thinks is just a sexual fling with Glenn Close’s character, Alexandra. But Alexandra becomes attached to Dan, and becomes increasingly unstable and manipulative, faking a pregnancy and attempting suicide in attempts to get Dan to leave his wife and stay with her, then trying to punish him and his family by breaking into their home and famously killing – and then boiling – Dan’s daughter’s pet rabbit. Ultimately, the only way Alex is stopped is when Dan’s wife Beth shoots her repeatedly in the chest.
Sarah: BPD is a troubled and troubling diagnosis, one that’s been criticized and theorized and analyzed by feminists, disability scholars, and so-called “borderlines” themselves. In this episode of our ‘borders’ series, we’ll explore the complicated history of a different kind of border: borderline personality disorder.
I’m Sarah
And I’m Elizabeth
And we are your historians for this episode of DIG
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Sarah: Feminist scholar Gloria Anzaldùa, in her semi-autobiographical book Borderlands/ La Frontera, explored the strange reality of borderlands based on her experience growing up as a Chicana woman in the Texas-Mexico border. As cultures and peoples meet at the border, they bleed into each other, Anzaldùa argues, creating a new space – a borderland. Anzaldùa explains: “Borders are set up to define the places that are safe and unsafe… a borderland is a vague and undetermined place created by the emotional residue of an unnatural boundary. It is a constant state of transition. The prohibited and forbidden are its inhabitants. Los atravesados live here: the squint eyed, the perverse, the queer, the troublesome, the mongrel, the mulatto, the half-breed, the half dead; in short, those who cross over pass over, of go through the confines of the normal.”[4] Anzaldùa was describing the realities of the actual Texas-Mexico border, but also the experience of those in the middle ground of other kinds of unseen borders, such as the borders of gender, sexuality, race, and ethnicity. As identities clash and conflict, the hegemonic (dominant) culture attempts to enforce adherence, pressuring or requiring people to meet cultural expectations (whether it’s of language, behavior, dress, cuisine, etc.). Yet, as scholar Janet Wirth-Cauchon summarizes, “these unnatural borders can never be fully enforced; fragments of the suppressed identities remain, in symptomatic traces or hauntings, preserved in muted form in the psyches or bodies of border subjects.”
Elizabeth: Numerous scholars have suggested that borderline personality disorder, in which a patient is trapped in a no-man’s land between Freudian poles of insanity, creates a similar borderland where definitions, identities, and demands clash. During the first half of the 20th century, the prevailing way of understanding mental illness was using Freudian psychoanalytic theory, which claimed that all mental illness fell into two poles: psychosis and neurosis. Psychosis, he argued, was when a patient had completely lost touch with reality, while neuroses were behavioral symptoms of environmental causes – repressed experiences and memories, for example. But in 1938, an American psychoanalyst named Adolph Stern described people who fell between those two poles as existing in a “borderline state,” exhibiting symptoms more severe than those with typical neuroses, but also not entirely psychotic. The term later came to indicate more than just a state of in-between-ness, but also a kind of instability and falseness, of a person who exhibited a “sham existence,” people who are skilled at appearing normal but who are really not.[5] One psychoanalyst described borderline patients as “stable in [their] instability.”[6]
Sarah: Patients who fell into this in-between state became known in psychiatric literature as “borderlines” themselves. This term is loaded, so I want to be clear from the beginning in my choice of words: I’m following the precedent set by BPD scholars like Susan Cahn and Merri Lisa Johnson in continuing to use the term “borderlines” to describe BPD patients, but also following their precedent, we’ll use them consciously and critically. We’ll talk more about the the name of the diagnosis and the various positions on it as the episode goes on.[7]
Elizabeth: In the mid 20th century, psychoanalysts came to see the borderline as something entirely new. Whereas in decades past psychoanalysts understood neuroses as stemming from people – men mostly – repressing their desires in order to adhere to the requirements of Victorian society, midcentury borderline patients seemed more severe, more anti-social, and exhibiting all the worst traits associated with modern society. Post-war psychoanalysts now saw the neurosis-psychosis divide as “the empty, grandiose narcissist” on one side and the “histrionic, manipulative, impulsive, and self-destructive borderline” on the other.
Sarah: In our episode on psychopharmaceuticals, we talked about how psychiatry has long been plagued by an inherent crisis of legitimacy. Certain factions within the psychiatric profession were continually frustrated that they couldn’t find clear cut causes or cures for mental illnesses, especially as they watched the medical profession seeming increasingly to unravel medical mysteries and develop effective new treatments. The example we discussed in that episode was penicillin, which could serve as a “magic bullet” against a broad spectrum of previously intractable diseases – psychiatry desperately wanted its own ‘magic bullet.’ While we were focused in that episode on medication, that same process – the attempt to make psychiatry more like medicine, with exact diagnoses and a profession guided by similar scientific principles – manifest in other attempts to change the psychiatric profession. For decades, psychoanalysis, which relies on hours and hours of intensive probing of a patient’s life history, dreams, and repressed memories, had reigned in the psychiatric profession. But the problem with psychoanalysis was that it was highly individualized. Each patient was unique. And while psychoanalysts could develop theories of mental illness based on trends, each diagnosis was based on extensive, individual analysis. In medicine, while a diagnosis might involve interviewing the patient a bit, the symptoms, labs, tests, etc., have to look the same – or at least virtually the same – from patient to patient. In other words, medical diagnoses are reproducible. And treatment options should also be roughly the same. For instance, two patients, from totally different backgrounds and life experiences with chicken pox should both have itchy pock marks, and both should respond similarly to calamine lotion.
Elizabeth: But of course, that’s not the way that diagnosis works within the psychoanalytic framework, right? Two patients might both be diagnosed with having neuroses, but each could have developed totally different kinds of neuroses for totally different reasons. We also previously discussed how not all psychiatric institutions and practitioners used psychoanalysis (especially psychiatric hospitals), but even those had no shared framework at all to guide diagnoses – so two different hospitals might use two different manuals or guides to help them determine a patient’s diagnosis. In the United States, there were five different diagnostic classification systems in the 1950s: an asylum system, an Army system, a Navy system, a Department of Veterans Affairs system, and the American Prison Association system. There’s one more layer here. Psychopharmaceuticals became increasingly popular for the general population at the same time as the rise of the American private health insurance system. And in order to get a health insurance company to pay for therapy or medication, you need to have a clear cut diagnosis that can be easily coded for medical billing. The ambiguous, complex, and highly individualized diagnoses of psychoanalysis just would not work in that system. So in 1952, the American Psychiatric Association (APA) published the first Diagnostic and Statistical Manual of Mental Disorders, or the DSM. The manual was based on the work of hundreds of psychiatrists, and while it created some standardization, it was still heavily based on psychoanalytic theory. The manual was lightly revised in 1968 (the DSM II), and during the 1970s, the APA elected to work on yet another revision, which would become the DSM-III. They selected Robert Spitzer of the New York State Psychiatric Institute, to head up the revision process.[8]
Sarah: Spitzer had been trained as a psychoanalyst, but had moved away from psychoanalysis and instead began developing a system of structured interviewing, where psychiatrists would ask all patients the same set of predetermined questions to land on a diagnosis. Spitzer saw the revision of DSM-II as an opportunity to move American psychiatry in that direction. The APA wasn’t particularly focused on the process, and so sort of gave Spitzer carte blanche for putting together revision committees, which resulted in a task force that overwhelming believed the DSM needed to provide precise and objective diagnostic categories. After their first meeting in the fall of 1974, the committee agreed that a DSM-III “should be evidence based, use diagnostic criteria instead of general descriptions, and strive for maximal reliability.”[9] The committees were especially concerned with personality disorders, which the APA defines as “ways of thinking, feeling, and behaving that makes a person different from other people,” and “a way of thinking, feeling, and behaving that deviates from the expectations of the culture, causes distress or problems functioning and lasts over time.”
Elizabeth: Personality disorders posed a particular problem for the committee because of their “amorphous and shifting nature” and lack of “hard evidence.”[10] They stemmed from the psychoanalytic focus on the development of a person’s character through lifelong conscious and unconscious experiences and the conflict between the ego, superego, and id. Psychoanalysts identified patterns in individual personality types and lumped them into a variety of personality disorders. These disorders were intrinsic to the individual – after all, they were part of who they were, right? And because of that, they were often associated with moral failure, personal weakness, and inferiority. Spitzer and his team were doubtful of personality disorders: they totally defied attempts at reproducibility, were highly individualized, and were typically intractable. But, try as they might, Spitzer couldn’t eliminate personality disorders entirely because, according to historian Hannah Decker, personality disorders were “clinically popular.” Put simply, they were useful to therapists.
Sarah: This placed Spitzer and his team in a tough position: theoretically opposed to the ambiguous personality disorders, but also beholden to the practicing psychiatrists who found those categories useful in diagnosis patients. In the end, Spitzer and his team eliminated four personality disorders (cyclothymic, explosive, asthenic, and inadequate) and added five (schizotypal, narcissistic, borderline, avoidant, and dependent). They also organized the entire DSM-III into what became called the ‘multi-axial’ system, where different kinds of issues were separated into ‘axes,’ through which a patient could receive a multi-axial diagnosis. Clinical diagnoses – needing immediate attention – made up Axis I, while personality disorders made up Axis II. Axes III, IV, and V dealt with medical and neurological factors, social and environmental factors, and assessments of distress and impairment. This allowed psychiatrists to give a patient a clear, treatable, and acute diagnosis – depression, anxiety, obsessive-compulsive disorder, etc. – that was recognizable by health insurance companies and acceptable to those who were skeptical about psychoanalysis, while also allowing for an additional diagnosis of a permanent, character-based personality disorder. (Side note: the multi-axial system was removed in the DSM-V in 2013 after decades of criticism.)
Sarah: I want to detour away from the story of the DSM to focus for just a minute about the experience of being diagnosed with a personality disorder. Susannah Kaysen’s reflections on the diagnosis of a personality disorder, detailed toward the end of Girl, Interrupted, gives us some insight into the first-hand experience of learning that it is your personality – not your brain or body or chemical make up or something – that’s somehow defective. When she read her case files, decades after she was hospitalized at McLean hospital, she struggled with each of the diagnostic criteria. For instance, one criteria was “uncertainty about several life issues, such as self-image, sexual orientation, long-term goals, or career choice, types of friends or lovers to have …” Kaysen begins to pick apart her choices. “Is this the type of friend or lover I want to have? I ask myself every time I meet someone new.” How can she tell what uncertainty is normal, and what is pathological? She also contemplated the nature of a personality disorder. What did it mean to have a disordered personality? “If my diagnosis had been bipolar illness, for instance, the reaction to me and to this story would be slightly different. That’s a chemical problem, you’d say to yourself, manic-depression, Lithium, all that. I would be blameless, somehow.” [11] She was still depressed, but “my misery has been transformed into common unhappiness, so by Freud’s definition,” she said, “she had achieved mental health.” She was discharged as recovered. “Had my personality crossed over that border, whatever and where it was, to resume life within the confines of normal? Had I stopped arguing with my personality and learned to straddle the line between sane and insane?”[12]
Elizabeth: Spitzer himself was a personality disorders skeptic and felt that if personality disorders were going to be added to the DSM-III, they needed to meet at least some scientific standard. But finding that standard was challenging. His initial research seemed to confirm his skepticism: when he approached psychiatrist Aaron Beck, an expert on depression, about a potential depressive personality disorder, Beck responded that “such a construct is so artificial and removed from observables that it is probably of little utility and, even worse, it is probably a misleading fiction.” But others insisted that personality disorders were real and important. Borderline Personality Disorder was the most troublesome for the committee drafting the DSM-III. Psychiatrists in particular urged Spitzer to add Borderline Personality Disorder, which one doctor insisted was “a discrete, diagnosable entity.”[13] Spitzer, the skeptic, felt that the term “borderline” was useless (because what did it mean exactly!?) but nonetheless asked BPD supporters to make their case. Eventually, Spitzer and his team decided that BPD should be added, but only if it was better defined and had a better name. For years, Spitzer solicited suggestions from American psychiatrists about what to rename the disorder – suggestions included schizoid personality disorder, unstable personality disorder, identity diffusion disorder, psychotic character disorder – but none of them stuck. In the end, the name borderline personality disorder seemed to be the only thing that worked.
Sarah: Spitzer still hoped he could nail down a clear description of BPD that would fit better in a new evidence-based, scientifically credible DSM-III – but just as with his attempt to change the name, this proved impossible. The description of the disorder that ended up in the DSM-III, published in 1980, included phrases like: “There is instability in a variety of areas …. No single feature is invariably present …. Frequently this disorder is accompanied by many features of other Personality Disorders … In many cases more than one diagnosis is warranted.”[14] That’s really not the clear cut diagnosis Spitzer hoped for. And the ambiguity has remained. Thomas McGlashan, former director of the Yale Psychiatric Institute, wrote: “the most important thing about borderlines: they are more different than they are similar.” Yet, he continued, they all shared the ability to make “a clinician’s hair stand on end,” so that psychiatrists “know when we have borderline patients in front of us even though we don’t know exactly what the illness is.”[15]
Elizabeth: One major indicator that a psychiatrist will feel that chill in his spine that tells him that he has a borderline in his office? The patient is a woman. As we mentioned before, the original idea of a “borderline” was a man, tortured by his Victorian repression. But we also said that by the 1970s, between 70 and 77% of all those diagnosed with BPD were women. What caused the shift? After WWII, the diagnosis was understood less as one about Victorian repression and more about a pathological inability to adhere to modern society. The postwar borderline is marked by four general categories of distress: “unstable self-image, chaotic interpersonal relationships, emotional lability, and marked impulsivity.”[16] According to historian Susan Cahn’s summary, borderline personality disorder “describes a kind of “empty self,” plagued by feelings of despair, loneliness, and a desperate fear of abandonment, problems that typically appear in early adulthood. The psyche defends against the resulting pain with a flood of unregulated, intense emotions, which include self-hatred, anguish, a fierce and clinging love, venomous anger, acute depression, and suicidal wishes. Desperate to gain a sense of control, the sufferer engages in impulsive, self-injurious behaviors ranging from suicide attempts or gestures to cutting and burning one’s skin or high-risk behaviors such as binge eating or spending, reckless driving, and sexual impulsivity, defined as sex with multiple partners, with relative strangers, and “without much forethought.”[17]
Sarah: It’s not hard to pick apart those diagnostic criteria to show how they disproportionately apply to women. Self-harm, such as cutting and burning, are much more common in women, as is binge eating. Other signs of BPD aren’t necessarily female behaviors but are considered inappropriate or problematic only when women do them – as Susannah Kaysen writes in Girl, Interrupted, “how many girls do you think a seventeen-year-old boy would have to screw to earn the label “compulsively promiscuous?”[18] Similarly, explosive anger is popularly understood as masculine –even a positive or unavoidable part of masculinity – but considered inappropriate in women. And if you think about movies like Fatal Attraction, we also associate “intense emotion,” “clinging love,” and “venomous anger” with women. (Aside: I think we also have that associate from a variety of headline-making murder cases, like the case of Clara Harris, who ran over her husband three times when she caught him at a luxury hotel with his lover in 2002, or Betty Broderick, who harassed and eventually murdered her ex-husband and his new wife in 1989; as well as theories about famous, beautiful women like Princess Diana and Marilyn Monroe)
Elizabeth: Historians, feminist scholars, and disability activists all argue that it’s not a coincidence that borderline personality became an overwhelmingly female diagnosis in the same decades marked both by second-wave feminism and the rise of the New Right. As Susan Cahn writes, “This shift in meaning occurred largely in the 1970s and 1980s, decades when radical feminists fought to legitimate women’s anger and sexual expression while simultaneously asserting a right to protection from physical or sexual abuse.”[19] In quick succession, disgruntled conservatives clapped back, decrying the breakdown of American morality, the degradation of the family, and the dangers posed by feminism. The diagnosis, largely applied to women, that pathologized anger, sexuality, and impulsivity, clearly seemed like an attempt to punish and control women who pushed back against traditional gender boundaries. Susan Cahn is clear that she isn’t arguing that this was a conscious process, but rather that within this larger cultural context, borderlines had traits that “were unsettling and discomfiting,” which influenced psychiatric trends. If society at large hates and fears angry, sexually active women, some psychiatrists will reflect that – after all, psychiatrists are part of society, too. As Susannah Kaysen’s psychiatrist told her, borderline is “what they call people whose lifestyles bother them.”[20] And we know this happens – again, you should listen to or revisit our episode on psychopharmaceuticals, because we talked a lot in that episode about how cultural ideas of femininity influenced drug development and marketing.
Sarah: So borderline personality disorder remained a messy, unclear diagnosis, one that was tied up with cultural ideas about femininity. But psychiatrists, eager to shore up diagnostic categories, often placed any instability in the disorder on patients themselves. Borderlines were untrustworthy, wearing “masks” and creating the image that they were well-adjusted to trick therapists. In Robert Knight’s 1953 essay describing the borderline state, he wrote that therapists might need to interview a patient many times because “in spite the patient’s automatic attempts at concealment, the presence of pathology of psychotic degree will usually manifest itself of the experienced clinician.”[21] Borderlines put up a “deceptive, superficially conventional, although neurotic, front” that therapists needed to pierce. As Susan Cahn argues, this is line with much longer trends in psychiatry that cast so-called ‘crazy’ women as seductive tricksters, who could present a normal face in public that masked deep, dangerous mental illness and defectiveness. Before the diagnosis of BPD formed, such women were labeled ‘psychopaths,’ who were unstable, impulsive, and self-obsessed but also charming and enticing. It also calls to mind the fear mongering of doctors and eugenicists who warned men about beautiful women who harbored hidden genetic flaws or sexually transmitted diseases. The borderline’s supposed tendency to hide their symptoms was what really created any ambiguity in the diagnosis.
Elizabeth: The ability to mask was also to blame for the tendency toward countertransference in therapists treating borderline patients. Countertransference is when a therapist becomes emotionally entangled with their patient. In the 1980s, several psychiatrists wrote articles describing the unique threat posed by the borderline patient, who would tempt the psychiatrist into such an entanglement. One wrote that borderline patients “get under the analyst’s skin,” with an “uncanny talent that enables the patient to ‘understand’ the analyst.”[22] Other psychiatrists wrote “when you’re treating borderlines ….I don’t care how good you are – they force whatever part of you is chaotic and crazy to get mixed up in their problems.”[23] In a particularly controversial essay in 1989, psychiatrist Thomas Gutheil wrote that borderline patients “possess the ability, as it were, to seduce, provoke, or invite therapists into boundary violations of their own in the countertransference.” Another suggested that borderlines discuss their struggles with therapists “in a basically coquettish, seductive manner, while the enthralled therapist struggles to match the priceless material with brilliantly penetrating interpretations.”[24] Yet another wrote that borderline patients “glitter and strike like a cobra.”[25] These men wrote to warn other psychiatrists about the dangers of borderline patients specifically, building the perception of female borderlines as dangerous, seductive sirens – but moreover, their arguments placed the blame for any inappropriate relationships between therapist and patient on the borderline. Susannah Kaysen captures this in an interesting way in a chapter in her memoir Girl, Interrupted called “The Shadow of the Real,” which brings to mind the theory that borderlines were hiding parts of their personality – a shadow self. In it, her therapist suddenly declares to her, “You want to sleep with me!” She writes, “sallow, bald early, and with pale pouches under his eyes, he wasn’t anybody I wanted to sleep with.” Later, her therapist gets angry when she makes a (apparently accurate) observation about how his three cars, a station wagon, a sedan, and a sports car, represent his ego, superego, and id. It’s the therapist, not the patient, who brings up sex and get irritated at analysis – but it becomes evidence of Susannah’s borderline personality disorder diagnosis.
Sarah: The dangerous allure of the borderline is captured in a memoir by Anthony Walker called – tellingly – The Siren’s Dance: Loving Someone with Borderline Personality Disorder. In the book, Walker describes coming upon a woman named Michelle on his rounds as a medical student in the 1980s. Michelle has just been revived and had her stomach pumped after a suicide attempt. While he pities her at first and describes her in grotesque terms – puffy and with the black from the charcoal still on her lips – when she smiles at him he is entranced. “Her smile was her lure,” he writes, “I was instantly seduced by it.”[26] He pursues her after she’s discharged, reasoning that she was never really his patient, and they eventually marry. He describes her as hypersexual, an inappropriate and impulsive whirlwind who, gasp! had once had a girlfriend and sometimes sent food back in restaurants. (I’m not kidding, lol) He says being with Michelle “was like adding a couple of dashes of Tabasco to fresh homemade vanilla ice cream.” (Which sounds … gross?) He describes his own obsession with her, but places the blame for that entirely on her and her illness. At the end of the book, he writes that most relationships aren’t like his and Michelle’s and that the book isn’t meant to be a cautionary tale, but in reality, the entire book is, like all those articles by psychiatrists in the 1980s, a warning to others to avoid the scary, dangerous, crazy siren.
Elizabeth: As we’ve described, the diagnosis has been consistently criticized by feminists, disability activists, and importantly, borderlines themselves. Patients, understandably, have had complicated feelings about the diagnosis. Susan Cahn analyzed several memoirs written by people diagnosed with borderline personality disorder, finding that patients fell all over the map in terms of their relationship to the diagnosis. Most express at least some ambivalence about it. Stacy Pershall, for instance, writes that she was “definitely” a borderline, but that she also hates the term. Others embraced the label, relieved to have something that captured and described their painful symptoms in a meaningful way. Rachel Reiland, on the other hand, wrote in her memoir that her diagnosis actually made her worse because it more or less gave her instructions on how to self-harm.[27] And Susannah Kaysen expressed skepticism about the diagnosis in general, writing that it’s “accurate but not profound,” and speculates that many of the symptoms of the disorder seem like fairly typical adolescent behavior.
Sarah: Borderline personality disorder is a diagnosis that has been extensively theorized, especially by feminist and disability theorists. Theory is not exactly the easiest thing to translate into audience friendly, easy listening, and it’s not something that we often delve into all that deeply here, but I do think it’s important to discuss it in this episode. Borderline is a troubled and troubling diagnosis, and we can’t really understand the nuances of it responsibly without at least acknowledging the different ways that scholars have worked to make sense of it.
In this episode, we’ve leaned heavily on the work of historian Susan Cahn, who is a mentor and good friend of all four of us. Susan uses Gloria Anzaldùa’s ideas about “border spaces,” where identities meet, conflict, and generate new identities, to analyze the ‘borders’ of borderline personality disorder. It can be tempting for scholars to see those borderlands as “frontiers of opportunity,” where new identities are generated and people can find freedom not available in other places or groups. In that sense, is borderline personality disorder actually disabling, or is it just another way of being that society punishes?
Elizabeth: At the same time, you could also take the idea that mental illness is socially constructed (Foucault cameo!) and apply it to borderline personality disorder to say, “well, it’s just another diagnosis, like hysteria, that was invented to punish and control women” and reject it entirely. In fact, we’ve talked about the anti-psychiatry movement before, specifically about psychiatrist Thomas Szasz and his theory that all mental illness is fundamentally a myth created by professionals and authority figures to control unruly members of society. Could we understand BPD as a tool for control, created by male psychiatrists, to label, punish and control female patients that violate the gender roles and don’t respond well to their expert therapies? Ultimately, we’re asking is borderline personality disorder real?
Sarah: Well, at the risk of falling into a DIG cliché: it’s complicated. It is “real” in that psychiatric professionals have identified a set of experiences and symptoms that come together that make it recognizable, but Susan argues that that still doesn’t make it “real” the way that Robert Spitzer and the DSM-III tried to make it. Therapists and clinicians don’t agree on what it is, struggle to describe it, and often try to use a “you know it when you see it” explanation of the disorder. Is it real? Yes – and no. The borderland as no man’s land.
Elizabeth: But there’s also a danger in flattening all mental illness into misogynistic attempts by the patriarchy to punish and control women. Feminist scholar Merri Lisa Johnson points out that several feminist scholars have turned borderline personality disorder into almost a metaphor through which they can explore the generalized pain of being a woman in a patriarchal society. But she counters that this “conflates women with extreme symptoms and women with nondisordered levels of distress.”[28] Women with borderline personality disorder are not just “intensified” women, or women who happen to be more traumatized or more oppressed. For example, Johnson describes a psychotherapist who criticized the idea that women with BPD are “damaged creatures.” This seems totally spot on, but Johnson pushes back: “Is it possible,” she asks, “that some people – people for whom the BPD diagnosis feels accurate and useful in identifying the dynamics of previously unnamed forms of discomfort and dysfunction – may desire access to a term like damage as a validating description of past experience and current states?”
Sarah: In other words, Johnson worries that the idea that BPD is just a tool of the patriarchy is actually too dismissive of the very real, and very painful, experiences of women diagnosed with the disorder. In a way similar to how white feminism fails to take seriously the unique needs of women of color, Johnson says that this neurotypical feminism fails to consider the unique needs of “psychiatrically disabled” women. Instead, she proposes neuroqueer feminism, an intersectional theory that “acknowledges neurodivergence, destigmatizes gendered neurodivergence, and values the experience and expertise of neurodivergent people.” You may have heard of the terms neurodiversity or non-neurotypical used in relation to autism; and as you probably know or have guessed, these are terms from disability theory that try to destigmatize autism and make space for minds that work differently from what has been deemed ‘typical’ by dominant culture. The term neuroqueer expands on that by drawing on queer theory, which explains departures from societal norms (as queerness diverts from compulsory heterosexuality). Neuroqueer, she says, means to be unapologetically neurodivergent. Neuroqueer feminism, then, fights back against stigma and shame while also allowing borderlines to claim their own experience as a disability, and welcome neurodiversity.
Elizabeth: That was a lot – and of course, we need to point out we really only unpacked two different scholarly views on BPD there. But that little dive into the theoretical approaches to understanding borderline personality disorder really illustrates just how complex the diagnosis is. Is it real? What does real mean? Either way, as both Susan and Merri Lisa Johnson – and the many memoirists we mentioned throughout – make very clear, borderlines do experience real pain. As several scholars have described it, borderlines have no “emotional skin” or “emotional clotting mechanism,” meaning they feel with extreme intensity and can’t stop.[29] How do we make space for those who find themselves in this borderland, and chafe at the label? How do we make space for those who embrace the label and find it useful? And how do we continue to interrogate the patriarchal use of this pain to pathologize, isolate, and punish while still ‘turning with tenderness’ toward borderlines?
Sarah: We don’t have clear answers to these questions because they’re all questions scholars such as Merri Lisa Johnson and Susan Cahn are still debating, and will continue to debate. And, well, maybe we’ll never have clear answers. In the borderlands, theories and experiences meet, merge, and conflict – so it seems likely we’ll always be discussing and debating. Normally, I like to end with a more definitive statement, but it’s hard with an episode like this. Instead, I think I want to reiterate Merri Lisa Johnson’s encouragement that we “turn with tenderness” toward borderline and those who live under that diagnosis.
Notes
[1] Susannah Kaysen, Girl, Interrupted (New York: Random House, 1993), 5.
[2]Susan Cahn, “Border Disorders: Mental Ilnness, Feminist Metaphor, and the Disorder Female Psyche in the Twentieth-Century United States,” in Disability Histories, Susan Burch and Michael Rembis, eds., (Urbana: University of Illinois Press, 2014), 259.
[3] Cahn, “Border Disorders,” 259.
[4] Gloria Anzaldùa, Borderlands/La Frontera: The New Mestiza (San Francisco: Aunt Lute Books, 2007), 25.
[5] Cahn, “Border Disorders,” 261.
[6] Cahn, “Border Disorders,” 261.
[7] For more on this language choice, see footnote 1 in Merri Lisa Johnson, “Neuroqueer Feminism: Turning with Tenderness toward Borderline Personality Disorder,” Signs 46 (2021), 637.
[8] Cahn, “Border Disorders,” 261-262.
[9] Hannah Decker, The Making of DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry (Oxford: Oxford University Press, 2013), 108.
[10] Decker, The Making of DSM-III, 195.
[11] Kaysen, Girl, Interrupted, 151.
[12] Kaysen, Girl, Interrupted, 154.
[13] Decker, The Making of DSM-III, 196.
[14] Decker, The Making of DSM-III, 199.
[15] Cahn, “Border Disorder,” 265.
[16] Cahn, “Border Disorder,” 263.
[17] Cahn, “Border Disorder,” 263.
[18] Kaysen, Girl, Interrupted, 158.
[19] Cahn, “Border Disorders,” 264.
[20] Kaysen, Girl, Interrupted, 151.
[21] Robert P. Knight, “Borderline States,” read at the joint session of the American Psychoanalytic Association and the Section on Psychoanalysis of the American Psychiatric Association, Atlantic City, May 12, 1952, 102.
[22] Cahn, “Border Disorders,” 272.
[23] Cahn, “Border Disorders,” 272.
[24] Cahn, “Border Disorders,” 272.
[25] Cahn, “Border Disorders,”273.
[26] Anthony Walker, The Siren’s Dance: Loving Someone with Borderline Personality Disorder, 6
[27] Cahn, “Border Disorders,”268.
[28] Merri Lisa Johnson, “Neuroqueer Feminism: Turning with Tenderness toward Borderline Personality Disorder,” Signs 46 (2021), 645.
[29] Johnson, “Neuroqueer Feminism,” 639.
Bibliography
Anzaldùa, Gloria. Borderlands/La Frontera: The New Mestiza (San Francisco: Aunt Lute Books, 2007).
Cahn, Susan. “Border Disorders: Mental Ilnness, Feminist Metaphor, and the Disorder Female Psyche in the Twentieth-Century United States,” in Disability Histories, Susan Burch and Michael Rembis, eds. Urbana: University of Illinois Press, 2014.
Decker, Hannah. The Making of DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry. Oxford: Oxford University Press, 2013.
Johnson, Merri Lisa. “Neuroqueer Feminism: Turning with Tenderness toward Borderline Personality Disorder,” Signs 46 (2021), 637.
Kaysen, Susannah. Girl, Interrupted. New York: Random House, 1993.
Knight, Robert P. “Borderline States,” read at the joint session of the American Psychoanalytic Association and the Section on Psychoanalysis of the American Psychiatric Association, Atlantic City, May 12, 1952, 102.
Walker, Anthony. The Siren’s Dance: Loving Someone with Borderline Personality Disorder .
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