Sham Diagnosis

The fiction of borderline personality disorder

Suffering, in its myriad forms, can be assimilated into medical and psychiatric discourses, and sometimes, at least, can become the object of treatment of these discourses. A diagnosis within these discourses is, therefore, strictly speaking a metaphor, a displacement, and it is the hallmark of delusion for what is metaphorical to be taken literally. Consider the expansion of mental health discourse over recent years, with an ever-growing cohort of professional lobbyists, advocacy groups and awareness campaigns. Fitness watches and their corresponding apps do not merely count calories or function as pedometers but quantify the amount of mindfulness one has undertaken. ‘Mental health’ has become central to the care of the self that subjects are supposed to perform for their ‘well-being’. The COVID-19 pandemic has illustrated this expansion very clearly. Pundits (often the same ones who support aggressive austerity policies) who were opposed to the Victorian government’s lockdowns and social-distancing measures bemoaned the alleged mental health effects of these strategies. In fact, suicide rates did not increase in Victoria during the lockdown period, but nonetheless the federal government took the extraordinary step of increasing Medicare funding for mental health treatments, doubling the number of sessions accessible per year from ten to twenty. This took place in a context in which practically every other aspect of the welfare state is being cut or systematically underfunded. ‘Mental health’ may be a way of naming individual suffering, but it also names a site of social and governmental contestation in terms of its funding and practices.

In the field that goes under the name of ‘mental health’, the purposes of diagnosis are varied, and go well beyond orienting clinicians in their treatment of patients. The social effects of a diagnosis can be far-reaching. ‘Schizophrenia’, to give one example, carries implications of madness, ‘psychopathy’ of moral depravity. Clearly, such labels carry a risk of stigmatisation for patients. On the other hand, however, some patients themselves clamour for a diagnosis, wearing it as sort of personal emblem in social settings and online forums. Just as astrology has its Pisceans and Virgos, so does the field of mental health include patients who strongly identify themselves as being ‘on the spectrum’ or as an ‘INTJ’, with these terms playing much the same role as the label of ‘addict’ in twelve-step programs. The label acts as a master signifier, linking and conceptually unifying disparate elements within an individual’s subjective life. It can function as a key through which, retroactively, people can make sense of their suffering. For this reason, people can become attached to their diagnoses, even when they are stigmatising.

Then there is the disciplinary function of a diagnosis. A case in point is that of childhood attention deficit hyperactivity disorder (ADHD). Studies have repeatedly demonstrated that among schoolchildren this diagnosis is disproportionately made of the youngest in the class or cohort. This suggests that what is being identified and pathologised is not so much a substantive underlying ‘disorder’ as a child’s inability or unwillingness to conform to the expectations of the adults in his or her life. A successful ‘treatment’—in the case of ADHD in the Anglophone world, this is almost always stimulant medication—is one in which this non-conformity has been suppressed. In the first instance, it is the adults in the child’s world, and not the child him- or herself, who has the problem. This is not to deny that some children do indeed display ‘hyperactivity’ or difficulties with attention, rather that there is a disciplinary element to the diagnosis and treatment that exceeds the amelioration of these symptoms.

Another example, one that will be central to this article, is borderline personality disorder (BPD). It is sometimes known by a less flattering term, ‘emotionally unstable personality disorder’ (EUPD). Whatever the clinical or empirical bases of the diagnosis, BPD has become a synonym for ‘manipulative’, ‘attention-seeking’, ‘difficult’ and ‘treatment resistant’. ‘Men’s rights activists’—largely unreconstructed misogynists—are wont to say that their unhappy experiences with women happened because the women in question had this particular condition. Beyond the pejorative implications, the clinical consequences of the diagnosis, in an Australian public health context, will very likely be refusal of treatment or refusal of a hospital admission. As Michel Foucault observed, formerly moral categories can, when under the auspices of medical ‘science’, be reconstructed into a diagnostic taxonomy. That this taxonomy speaks the language of medicine does not prevent the moralisation from continuing.

The origins of the borderline

The concept of the ‘borderline’ is intertwined with the history of psychoanalysis in the United States. Almost all of Sigmund Freud’s early disciples were Jewish, and the rise of fascism in Europe resulted in a great diaspora, with psychoanalysts relocating to Paris (for a time, at least), London, Chicago, New York and Buenos Aires, among other destinations. Differences in language and culture effectively ensured that psychoanalytic theory and practice underwent very different trajectories in each of its new homelands. Freud founded the International Psychoanalytic Association (IPA), and the origin of the BPD diagnosis is tied very closely to the advocacy of this group. The IPA claimed an institutional lineage that derived directly from Freud, but some have argued that this institutional legacy conceals profound betrayals of Freudian theory and praxis. French psychoanalyst Jacques Lacan, for example, who was ultimately expelled from the IPA, accused this latter of breaking fidelity with Freud’s founding principles by extracting the radical elements from psychoanalysis, and subordinating it to imperatives of ‘independence’, conformity and heteronormativity. Freud and Lacan permitted ‘lay’ (i.e. non-medical) analysts to practice, provided that they had undergone their own analysis; the IPA largely rejected this, seeking to shore up the group’s scientific prestige. Freud was tolerant of homosexuality, despite the conservatism of his surroundings, and Lacan declared that there were no pre-established sexual relations between humans at all, but well into the 1970s the IPA maintained that homosexuality, for instance, was a perversion, even as crudely bioreductionist psychiatrists were disputing this. In Paris at the time of the May 1968 uprising, IPA analysts dismissed the students as ‘infantile’; Lacan met and held seminars with them. In short, there are some major differences between the IPA and other psychoanalytic orientations.

In any case, Freud never set out to make a systematic diagnostic classification system in the style of the DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders, touted as the ‘bible’ of psychiatry by its authors). He did, however, maintain a diagnostic distinction between neurosis and psychosis. In neurosis, a patient is separated from his or her most intimate or traumatic memories, wishes and fantasies by a process called repression, when these phenomena come into conflict with the ego. In psychosis, there is a similar problem of conflict with the ego, but instead of its giving rise to repression, the psychotic subject alters his or her relations with the ‘external world’, as Freud put it. Psychoanalysts subsequent to Freud came to use this distinction as a guide as to whether a patient could be analysed. A neurotic was analysable in this system, but in psychosis, whether the patient in question was schizophrenic, or melancholic, paranoid or manic, the potential for analysability was much less clear. Some schools of psychoanalysis to this day dispute the applicability of psychoanalysis to psychotic subjects.

Into this distinction stepped two US psychoanalysts of the mid-twentieth century, Robert Knight and Adolf Stern, who designated the existence of a border zone between neurosis and psychosis. Under stress, a borderline patient may exhibit symptoms similar to those in psychosis, but under better conditions these symptoms may dissipate. Note that the origins of the borderline diagnosis are, first, as a wastebasket category and, second, as a means of assisting clinicians who are, strictly speaking, the ones on the border, faced with the difficulty of making a clear diagnostic distinction.

Several decades after this innovation, psychoanalysis was no longer the pre-eminent clinical paradigm for mental health in the United States. By the 1980s, psychopharmaceutical medications had rapidly proliferated, and talking therapists tended to favour techniques of direct suggestion (such as those in behaviourist or cognitive therapy) over psychoanalysis. The DSM was published in its third iteration in 1980, and its main architect, Robert Spitzer, waged a battle to replace the document’s psychoanalytic lineage (IPA only, by this point) with an orientation that was explicitly more biomedical. Psychoanalytic terms and diagnoses were largely purged from the DSM, but, as a sort of concession to the American psychoanalysts, a second ‘axis’ of diagnosis was added, incorporating a number of so-called ‘personality disorders’, among which was BPD. Never mind that there is no unified conception of what a personality is, nor how it can be ‘disordered’, and that accounts of personality differ considerably depending on a given psychoanalytic school, and vary even more greatly if one is a psychometrician or a cognitivist. And never mind that many psychoanalysts around the world reject the use of the BPD label as stigmatising and unrigorous. BPD had become canonical in mainstream medicine and psychiatry.

The construction of the borderline

Having brought BPD into ‘scientific’ respectability, the task of the DSM’s nosologists was to assign it a set of positive criteria far removed from the wastebasket theorising of IPA psychoanalysis. The BPD diagnosis is still prevalent within IPA psychoanalysis, but its terms—above all, ‘projecting’ and ‘splitting’—are by now radically different to those of psychiatry. The psychiatric definition of BPD instead is as follows:

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 behaviour covered in Criterion 5)

2. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation 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 behaviour covered in Criterion 5)

5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour

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.

Several observations are worth making here. First, most of the criteria refer to near-universal aspects of human experience, which vary quantitatively between individuals. Mood as such is mutable and ‘reactive’, and people generally try to avoid real or perceived abandonment. Second, there is a subtle but distinct strain of moralising, wherein certain bodily satisfactions—food, sex, self-administered substances—are viewed through the lens of ‘self-damaging’ behaviour. Third, the would-be diagnostician is granted considerable power to exercise what are strictly subjective and arbitrary judgements. For instance, what precisely is an ‘inappropriate’ level of anger, and how would one gauge this objectively, especially in the absence of a mediating context? The diagnostic criteria on the whole tend to pathologise various manifestations of distress without any reference to the cause of this distress.

It is worth noting further that these criteria are disproportionately applied to women rather than men, and that women are diagnosed with BPD at a rate of three to one relative to men. Moreover, even if one is prepared to entertain the validity of BPD as a construct, it is striking that the most significant etiological factor is what the literature terms ‘environmental’. Up to 70 per cent of those diagnosed as borderline have a history of serious trauma, often in the form of childhood neglect, or physical and sexual abuse. The aim of DSM diagnosis is essentially one of generalisation on the basis of symptoms, but implicitly this generalisation is gendered, and imbued with a set of social norms regarding suffering, satisfaction and an individual’s relation to others. What are supposedly ‘neutral’ criteria expressed without value judgements are in fact deeply ideological constructs in pseudo-scientific garb. Lacan referred to ‘discourse’ as the means by which language forms different types of social bonds. There are many such discourses, and that which he termed the university discourse speaks in the name of knowledge, of science, but conceals (and produces) relations of mastery. Contemporary mental health is one example of such a discourse, and anybody taking up the label of BPD as their emblem, as encouraged by the diagnosticians, is liable to become an agent of their own subjection.

Mental health, politics and neoliberalism

The field of mental health in general, and psychiatry in particular, has a long history of political ideology being passed off as ‘science’. The most notorious examples are perhaps those of the twentieth century’s dictatorships. The USSR effectively used psychiatry, with its attendant threats of forced treatments, confinement and sedation, as a tool for managing dissidents. (Nobel Prize winner Joseph Brodsky, for instance, suffered a stint in a mental institution for ‘pornographic and anti-Soviet’ writing.) Even more striking was psychiatry in Nazi Germany. What is particularly remarkable about the Nazi psychiatrists is that much of the killing perpetrated by psychiatrists—estimated to be in the order of 200,000 patients—occurred before any executive order from Hitler or other senior Nazis, and was undertaken with the imprimatur of German academic psychiatry. If this seems like an outlier, we should recall that a significant portion of psychiatric thought outside Nazi Germany, and particularly in the United States at that time, was grounded in the eugenics movement, and supported the notion, for instance, of administering euthanasia to the ‘feeble minded’.

The liberal democracies too were not immune to abuses within the field of psychiatry. In the United States, in 1851, one Dr Samuel A. Cartwright notoriously posited the existence of ‘drapetomania’, a madness in which the afflicted were slaves possessed with an intense desire to escape. Among the remedies prescribed by Dr Cartwright included ‘whipping the devil out of them’ and preventing further absconding by removal of the patient’s toes. A diagnosis of schizophrenia in the 1950s was characterised by a splitting or fragmentation of the personality, usually resulting in a calm, if poorly functioning patient. The diagnosis was disproportionately made of women, particularly housewives. In 1968, the DSM underwent its second revision. That year was famously one of protest across many parts of the world, including the United States, which saw mass movements in opposition to the Vietnam War and in favour of civil rights. When the DSM-II emerged in the context of these societal conflicts, schizophrenia had been redefined with an emphasis on ‘masculinised belligerence’, according to historian of psychiatry Christopher Lane. With schizophrenia now recast as a condition characterised by ‘hostility’ and ‘aggression’, the primary candidates for the diagnosis shifted from white housewives to African American men, many of whom were directly involved in civil rights protests. The effect of this shift was that many such men were hospitalised, often for years at a time, and subjected to mandatory ‘treatments’. Silencing dissent or, even worse, pressing the dissenter into express agreement with some ideology or other, has been an aim of mental health intervention.

The ideas of the ruling class are, in every epoch, the ruling ideas, and this is as true of mental health and psychiatry as anything else. The current ruling ideas are decidedly neoliberal. The effect of neoliberalism on the field of mental health is not merely to seclude, kill or disable dissidents, though that still occurs. More commonly, the contemporary patient of neoliberal mental health is obliged to uphold the virtues that are highly esteemed by the ideology. It is probably not a coincidence, for instance, that the shift from institutionalisation towards self-management of mental disorders occurred at precisely the same times and in the same places as government economic policy moved from Keynesian social democracy to neoliberalism. As the political economy changed, so too did psychiatric technology, with lower-risk SSRI medications and cognitive therapies replacing sedatives and lobotomies. The move towards self-management is more fiscally prudent and, moreover, the neoliberal paradigm posits each individual as his or her own entrepreneur, with a fundamentally different social contract with the state to his or her Keynesian predecessors. Viewing individuals primarily as entrepreneurs allows us to view their difficulties in life as the result of malinvestment. Unemployment, sickness and other life problems, in this view, ought not to receive too much in the way of governmental amelioration, since this would effectively prolong the malinvestment, and obstruct other, better investments. In this paradigm, suffering people ought not to receive too much help. This is not always stated explicitly in the textbooks—though sometimes it is—but it nonetheless is a massive influence on the provision of mental health services. Dependence is systematically pathologised when it involves a dependence of people, though not necessarily if it involves the use of prescription medications. Patients are encouraged to ‘individuate’, but not from their pharmaceuticals, ‘pleasant activity schedules’ and mindfulness apps. Individuation is held by researchers in this field as a self-evident good, thus demonstrating that the hallmarks of psychology, ‘well-being’, ‘maturity’ and ‘self-regulation’, consist in reproducing the isolated, alienated subject of liberal capitalism.

In order to understand the effects of neoliberalism on mental health policy, it is important not to see it simply as cuts to funding, or competition between services—though it is those things—but also as the internalisation of a different set of prerogatives within the services that survive. For instance, several major psychological treatments for common mental afflictions regard negative affect as the outcome of invalid reasoning, or as something a person can be diverted from by distraction, meditation, so-called thought-stopping exercises, enhanced self-regulation and so on. Subtly but surely, negative emotions become an indication of a moral fault. When it comes to mental health treatment delivered by words, the latest thrust is for technology to be used to deliver directive strategies, which patients would self-administer by way of apps or computer programs. One can see how, in the present climate, such apps appeal both to a narrative of ‘innovation’ as well as to a desire to save money. But one of the most empirically robust findings in the history of mental health, dating back to at least the 1930s, is the importance of the therapeutic relationship in determining the outcome of a treatment. In the context of a collapse of many social structures, and arguable increases in isolation and alienation, self-administered apps may very well aggravate the problems they purport to treat. The borderline, with her fear of abandonment and appeal to the other for support, is at an impasse here, and her ‘neediness’ and ‘dependence’ are liable to be read as symptoms under the dominant paradigm.

The borderline under neoliberalism

Julia Kristeva, in Powers of Horror, situated borderline phenomena with the ‘abject’. The etymology of this term is significant, as the Latin refers to that which is thrown away. Kristeva was writing in 1982, but this term captures very precisely the position of the borderline with respect to contemporary mental health. Officially, whether in legislation or the policy of the major hospitals, there is no prohibition on admitting BPD patients during a bout of suicidality or acute psychotic symptoms. Practically, however, such rejections are a daily occurrence, with the prevailing attitude being that the risk with BPD is in providing too much, rather than too little, care. Just as with Centrelink, where ‘support’ for dole recipients is minimal and punitive, for the recipient’s supposed own good, so too does the borderline run the risk of indulging in ‘secondary gain’ in the face of undue assistance. Consequently, the treatment protocols for BPD sometimes enjoin clinicians to refrain from indulging a patient presenting with suicidal gestures. To quote from one (Borderline Personality Disorder: A Clinical Guide, by John G. Gunderson), suicidal acts are potentially ‘manipulative’ and will lead to ‘secondary gain’.  The prudent clinician, confronted with these gestures, should remain ‘uninvolved’ and ‘unavailable’. Again, to reiterate, the majority of such patients have a background of serious trauma, often experienced at the hands of those who raised them. Treatment is directed at having them ‘self-manage’ this trauma in such a way as to impose only minimally on public services. This is not merely a neutral, ‘scientific’ procedure but one in which mental health services are animated by the prevailing political economy and its ideology.

The concern about ‘secondary gain’ here is particularly ironic, as the term derives from Freud. The primary gain of a symptom, according to him, was the quantum of satisfaction that it produced. (The sort of satisfaction that he had in mind is something radically distinct from what we might term ‘pleasure’.) Freud introduced the idea of secondary gain in his Introductory Lectures on Psychoanalysis, in which he discussed ‘advantages’ that might accrue from a given symptom. He gives the example of a woman ‘roughly treated’ (as James Strachey translates it) by her husband. Her illness provides her with a modicum of defence against her husband’s aggression. Freud did not argue that the woman in question should be deprived of such defences but instead suggested that they would likely be intractable in the absence of a solution to her marital problems. Any ethical treatment worthy of the name would be obliged to consider alleviating the patient’s marital problems, and not merely silencing her neurotic symptom.

One can consider this in the light of Lacan, who once quipped that it was Marx who invented the symptom. One reading of this is to understand that the point of conflict within a system, whether at the societal or familial level, and which may well be localised within a given individual, is produced via a structural causation beyond that individual. The child diagnosed with ADHD may be the one given the dexamphetamine, but his or her family and classroom may also require a treatment of their own, and likewise for the borderline. The contemporary neoliberal paradigm for mental health diagnosis and treatment aims at silencing symptoms and their context without regard for the social problems that have given rise to them. Insofar as interpersonal, non-pharmaceutical treatment is provided to BPD patients—and this is extremely minimal in the public system—it tends to involve an elaborate series of microregulatory, didactic methods for self-management without discussion of the patient’s history. A prominent private hospital in Melbourne, for example, offers an ‘emotional management’ program in which patients are taught modules such as ‘Emotion Regulation’ and ‘Distress Tolerance’. The particularity of an individual’s suffering is ignored in favour of generic techniques and the provision of information, rather than care as such. This impersonal, one-size-fits-all approach to treatment makes it to psychology what Ceaușescu’s orphanages were to parenting. Those aspects of BPD that are given the most attention are those that are most distressing to hospitals and not necessarily the patients themselves. Moreover, the fundamental problem of the BPD patient is construed as an educative failure. He or she is held to be an undivided, self-reflexive subject with no unconscious and no relevant history, who merely needs to acquire the right knowledge in order to be well regulated. The last two and a half millennia of philosophy, Eastern and Western, might as well not have existed as far as contemporary mental health treatment is concerned.

To be clear, the need for particularised care within the field of mental health is not a call for personal therapy at the expense of social measures. The government could do more for the mental health of the populace by improving housing, health and unemployment benefits than by providing any kind of awareness campaign or psychiatric treatment program. That suffering always contains an irreducibly subjective component, in psychoanalytic theory, does not alter the fact that the kind of subjectivity that exists within psychoanalysis is one that is founded on a relational ontology. This is especially true in Lacanian psychoanalysis, in which there is no ‘self’, as such, except imaginarily, and the subject who exists instead is one that should be read as having been ‘subjected to’ the social order, from the level of the family up to the broader society. The most intimate, most ‘biological’ aspects of life—sleep, eating, toileting, sexuality—have been thoroughly socialised before a child can typically write his or her own name. Consequently, when thinking about the causation of ‘symptoms’, as these are understood in mental health, one is apt to be led astray unless both subjective and social structures are taken into account. It is to the benefit of neoliberal governments and mental health providers under the dominant paradigm to obscure the dual structure of symptoms, and to pretend instead that said symptoms correspond to some underlying biological impairment or, better yet, a moral failing.

Criticisms of the diagnosis and treatment of BPD are growing, and in various parts of the world service users and researchers are providing trenchant critiques and offering alternatives. This allows for the possibility that somebody with a history of trauma who presents as suicidal at a clinic might yet be viewed as something other than a manipulator to be turned away or cajoled into conformity. Australia, however, is lamentably backward on this point, and one will search in vain in the official statements of the major mental health providers for the slightest acknowledgement that such critiques of BPD even exist. The concept of a ‘disordered’ personality is itself taken up uncritically by the leading Australian mental health institutions, who also regard such disorders as bona fide medical in nature, to be (self)-managed along the lines of diabetes or high blood pressure. The suppression of history, particularly historical trauma, and the denial of care to a particular group of patients is not the application of some apolitical, medical procedure. It is thoroughly reactionary, and continues the worst traditions of psychiatric care, updated for the neoliberal age.

About the author

David Ferraro

David Ferraro is a psychoanalyst in Melbourne. He is a current member and former president of the Lacan Circle of Australia, and gives a seminar on the politics of mental health at the University of Melbourne.

More articles by David Ferraro