Editorial note: This case example is fictionalized. The individual described below is not an actual person, and any resemblance between this fictional person and any actual person is coincidental. This is a co-authored paper and the authors sometimes use ‘I’ instead of ‘we’ for clarity and continuity reasons.
A referral came via e-mail: She was a 31-year-old Caucasian female who reported, “I need to leave my boyfriend of seven years, but I don’t know how to.” The psychiatric history check-box was clicked for “significant” and the past reported diagnosis was ‘Borderline Personality Disorder.’ I called her and we set up a time.
Sophia arrived roughly 10 minutes early for her appointment time and was quite polite. She took her seat, thanked me for my time and asked what she should tell me. “Whatever you’d like,” I responded.
Over the years, I’ve heard countless horrific stories of abuse, neglect, trauma and most every form of torment that one human can inflict upon another. The sting of such stories never lessens. I’ve often marveled at the mind’s capacity to focus a sustained attention upon new ways to perpetuate and promote anguish. Sophia’s story is tragically similar in regards to the abuse she suffered. Her life, by her convincing account, was really an endless series of disappointments and traumas, of every imaginable variety, layered on top of one another.
Her childhood experience sensitized her to the pain of other living things, both animals and humans. She volunteered at an animal shelter, but she had to leave to find gainful employment. Sophia set her sights on psychology and decided she should get her own therapy along the way. She was caught, much like her mother, in an abusive relationship which she could neither tolerate nor leave. Unlike her mother, there wasn’t any physical abuse, but she described her partner as controlling, rageful, demeaning.
She was perplexed; she could leave the relationship at any time — she saw no real threat or danger in leaving. As a matter of fact, she desperately wanted to, but couldn’t for some unknown reason. In this relationship she acknowledged her own rage, cynicism and derision directed towards him, but it was present prior to him and also outside of romantic relationships.
Relationships were intolerable, yet completely needed. Sophia couldn’t afford most therapists, but seemed to make a sincere go of it, paying what she could and engaging in the best way she knew how. The diagnosis of ‘Borderline Personality Disorder’ seemed to be the only consistency between the various therapists she saw over the years. She took a break from therapy after, apparently, a therapist told her that her stories were too disturbing. The therapist discontinued the work after roughly four sessions and Sofia took with her another layer of rejection.
Something in her wouldn’t give up. She had faith. I am not sure if it was faith in herself, faith in the process or if she was simply inspired to take the proverbial leap of faith again. Perhaps it was some combination therein, but she called and showed up.
“Am I borderline?” — A lot of clients ask me this. One doesn’t have to be a psychology student or a professional to know that this is the psychiatric label demarcating an especially disturbed, even dangerous, person. “I don’t know,” I responded. “I don’t really use psychiatric labels that often. Is the diagnosis helpful to you or has it been helpful in some way?” The answer came easily, quickly: “No, I understand what it means. I’ve read all about it. They really accent it in school. Even though I don’t find it helpful or useful, there’s still something wrong. I don’t like the way I feel. I don’t like who I am with people sometimes, friend and family too. I don’t like not being able to leave this relationship and not knowing why. I am broken.”
And here we stand at a crossroads. The ‘standard-normal’ mental health professional would know, as this client did, what the label ‘borderline personality disorder’ means. Generally speaking, it refers to a relationally and emotionally unstable woman. (Despite research to the contrary, the DSM continues to list women as being predominantly the ones suffering from this affliction). As a ‘personality disorder,’ the condition, by definition, is chronic and unremitting. Most insurance will not cover it nor any other personality (i.e. Axis II) disorder.
The standard protocol when faced with ‘borderline personality’ is to refer the person for a psychiatric evaluation and to Dialectical Behavioral Therapy (DBT), a manualized psychoeducational program specifically designed to treat this ‘condition.’ For some, this may be helpful. While I remain critical of psychiatric labels and psychiatry as a whole, I would never want to tell someone, who may find these things helpful, that they’re wrong. I don’t see myself as someone who tells others what to do. I lay out the possibilities as I see them and partner with people, meeting them where they’re ‘at,’ to accomplish the things they want to accomplish.
I’ve had some clients come to me after completing a DBT program or two, usually grateful for some of the skills they’ve learned, but wanting something more. They usually say that DBT offers some practical and useful tools, but that life is about more than utilizing such things. Moreover, there tends to be a lingering sense of something yet to be accomplished. This may be something like, “I am broken,” or perhaps a desire to become centered, well and successful (as the individual defines those things for his- or herself). Most people, said differently, do not want to simply lead a reduced-symptom life, facing a perpetual recovery from some purported psychiatric disease.
A medical-model, pathologized view is one way to understand varieties of psychological distress. It pretends that it’s the only view, hence it tends to be taken as fact by most people emerging from psychology and related programs for the last few decades. Yet, the force and even hegemony of a perspective does not make it a fact. Said differently, most people (not just students and professionals) assume that behaviors, thoughts and affects are the result of electrical-chemical activity of the brain organ. An abnormality in the smooth everyday functioning of the brain organ is, then, what explains ‘abnormal,’ — potentially a disease. These abnormalities/diseases are considered to be like cancer or diabetes — no further thought is needed. Actions and aberrations of the brain organ are, much like wind, gravity, rain, an act of Nature. They just happen.
But what if the assumptions of the medical-model approach are incorrect? Again, because a series of hypotheses and propositions are popular or continually assertively put out there, that doesn’t necessarily mean they’re correct. In our book Borderline Personality Disorder: New Perspectives on a Stigmatizing and Overused Diagnosis (Praeger, November, 2014), we demonstrate that ‘borderline personality disorder’ is a cultural-historical construction typically foisted upon women with a history of developmental stress and/or trauma. This is the case for every purported psychiatric disease outlined in the Diagnostic & Statistical Manual of Mental Disorders (DSM). These supposed psychiatric diseases did not somehow simply land here, in 2014, out of the blue. Not only do the various diagnoses outlined in the DSM each have their own narrative history, but so too does the DSM itself.
In any event, we consider the following when addressing so-called ‘borderline personality disorder’ or any distressing state of mind. In no particular order:
- Varieties of psychological distress are the logical outcome of early developmental stress and/or trauma; they are not diseases. Moreover, no psychiatric nor any other label is necessary if one simply sticks to the person’s experience descriptively.
- All people are capable of growth. There is a clear and sustained focus upon pathology in psychology and related fields. While this is understandable to the degree that psychology and related fields need to focus on what’s problematic, this view has become stubborn and rigid. It is not always the case that it is wise to focus on the pathological. More often than not, it is more beneficial to focus on the growth capacities of the whole person. Also, from the perspective of metanoia, everything that is distressing is the person’s attempt to achieve wholeness. That is, distress is often on its way, so to speak, to something further, more complete, whole. In this way, our approach is reminiscent of Karen Horney’s recognition of the problematic, but (more importantly) the person’s abilities to learn, adapt, grow and integrate.
- There is no cookie-cutter, one-size-fits-all approach to growth processes. What ‘works’ best is usually a combination of different approaches tailored to one’s unique circumstances and history. For this reason, we provide a Wellness and Recovery Resources directory in the text.
- Despite the type of modality sought, a hierarchical relationship is not only not necessary, but can be harmful. It is usually wise to work in a collaborative partnership — to wrestle, together, with the questions.
Applying this collaborative approach to Sofia, we were able to negotiate together between the spaces between the (ascribed) ‘borderline personality disorder’ and the (self-reported) “I am broken.” Sophia decided to stop understanding herself as being ‘borderline.’ She cast aside the label. We talked about the “I am broken,” and differentiated it relative to different people and contexts. Now, roughly a year later, she reports, “I am no longer broken with my family and friends. I am no longer broken with my coworkers and at school. I am still with him, but am understanding that more, too, and am less attached, somehow.” Sophia still talks to me once in a while, but has successfully found where she feels most at home and serene — in Nature. She has also significantly adjusted her diet after doing some research. She recognizes that there is no ‘cure’ to be found, since there is no disease. It is a matter of finding what ‘works’ in finding one’s rhythm with life.
As I was writing the brief section on pathologizing and growth, it struck me that most people consider psychotherapy, psychoanalysis, recovery, wellness, etc., resources only within the context of suffering. These are, of course, perfectly great resources to utilize in contending with distress. But this, too, I suspect, is falling in line with the pathologizing model. It is equally true that these (or other) resources can be harnessed to further one’s desires in life. Not every resource has to be utilized relative to pathology. Perhaps one is simply interested in psychological life or how to be more successful in this or that venture. Sometimes an individual wants to know how to be a better person to his or her friends, family, and other relationships. Others are interested in dreams or discovering different combinations of approaches that work for themselves and maybe for others. People who have suffered often come to the point of feeling satisfied with their growth and want to somehow express it. I have seen many artists, poets, activists, recovery sponsors/mentors, peer bridgers, therapists, psychoanalysts, etc., emerge from their own metanoia with a burning curiosity to know more, to take things to the next level, whatever that may be for them.
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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.