Living on the Borderline
September 2, 2016 11:34 AM   Subscribe

When insolent kids and women are the only ones pathologized for throwing temper tantrums as opposed to violent behavior, then the discourse is suspect.

Dr. James Higginbotham explores implications of the politics of the DSM
posted by Dressed to Kill (40 comments total) 35 users marked this as a favorite
 
Can I get a précis on this?
posted by Faint of Butt at 12:16 PM on September 2, 2016 [1 favorite]


Summary: "The question is whether Axis II of the DSM, which classifies disorders of personality, is largely speculative and ultimately political in nature"

The answer, according to him, is "yes"
posted by Dressed to Kill at 12:19 PM on September 2, 2016 [6 favorites]


Anecdotally, I feel like trans women get stuck with the "borderline" label when - as is suggested in the article - PTSD or depression might seem like better fits. And when some of the behaviors that get you labeled "borderline" can be read as stress behaviors - as we all know, trans women face far more housing insecurity, job insecurity and violence in interpersonal relations than lots of other groups.

Also anecdotally, "borderline" is popularly understood as an incurable, "dangerous" disorder. Being diagnosed (or even labeled by peers without any diagnosis) as "borderline" can be really destructive. People who are marginalized can take it to heart as a sign that they are broken.

I have gotten really skeptical of this diagnosis over the years because I've seen it applied to people whose life conditions would give me the howling fantods, and I feel like it's weird to say "you are homeless, you've been sexually assaulted multiple times, you have an untreated medical condition, you aren't eating regularly or sleeping deeply, and people in your social circle treat you with disdain...clearly we can determine that your rage, panic, weird emotional reactions and so on are totally separate from the stress and pain of your life".
posted by Frowner at 12:24 PM on September 2, 2016 [80 favorites]


It's frequently further abuse of already abused women. I remember when I was hospitalized for rape trauma and PTSD dissociation I was hiding behind a chair and said I didn't want to talk to a man due to numerous years of sexual abuse and trauma. He said I had "drama personality". And also, well if I got abused that long why did I stay? What was my role and what's wrong with me for staying? Surely it was just my choice to stay in that, and it's ridiculous to want to avoid some innocent good psychiatrist who wants to label and have power over me. That was my first experience trying to get help with trauma after abuse.


The institution of psychiatry and psychology are so married to patriarchy and classism and patronizing assumptions about fellow humans that I think we need to just burn down the framework and rethink everything. Psychologists and psychiatrists have operated in a power vacuum where there are few objective standards to keep their bullshit from proliferating and taking on a status as fact where there is no such evidence existing. They don't have to provide evidence when they simply have expert status, and a lot of theory bases are based on a couple of badly framed research studies with very few participants and a pet theory taken far more seriously taken as fact than it should have been, with serious impacts and harms to real people.
posted by xarnop at 12:26 PM on September 2, 2016 [46 favorites]


Also, living as I do in a house with a spare room sometimes filled by a friend or an acquaintance, I have noticed that for many people, what seem like severe, intractable borderline/inappropriate affect/weirdness-type mental health issues improve out of all recognition after a few weeks of sleeping in a clean, appropriately heated and cooled room with a real bed and a door that can be closed.

It isn't that mental health issues aren't real, but the older I get, the more I recognize how the issues tend to be exacerbated hugely by housing insecurity. What might be a manageable condition with secure housing turns into a life-shattering one because of lack of sleep and stress.
posted by Frowner at 12:28 PM on September 2, 2016 [108 favorites]


My mom has been diagnosed with BPD, and I recently was diagnosed with possible PMDD. The stakes are super high to get this stuff right.

I gave this article to my colleague, a psychologist, who flipped through and said, "hmm.. yeah this really is your cup of tea, isn't it?"

I snapped, "Yes...well as a member of the oppressed gender, I have a large stake in it... as well as 50% of our [hospital's] patients"
posted by Dressed to Kill at 12:33 PM on September 2, 2016 [15 favorites]


Among women mental health workers I know, "borderline" is giving way to a working diagnosis of "emotional intensity disorder." It's understood as a disorder that, like depression and anxiety, is responsive to treatment. I find this new take much more helpful when dealing with people exhibiting "borderline" traits.
posted by epj at 1:00 PM on September 2, 2016 [11 favorites]


I agree BPD is absolutely used to minimize and ignore women, used as a diagnosis to liberally dismiss important dynamics of trauma, relationships and stable enviroment.

But there are people who have it, and these people really truely have tons of difficulties in their lives even when their lives are economically stable.

It's an absolutely heartbreaking disorder. People who litterally cannot hold a since of self in relation to another person at all. The key here is hold - establishing a relationship pattern that varies but has a baseline. But, in BPD that doesn't happen ever. Feelings affect the entirety of their perspective in the moment from great to terrible and can be influenced by stimuli that has nothing to do with the actual relationship in question. Because of this, they rarely have relationships lasting more than a few months, never complete educational achievements, cannot hold jobs, and are emotionally up and down all the time. They are desperate, lonely people who have great difficulty with changing behaviors, and difficulty learning from social mistakes. Their thought processes reinforce their behavior rather than calm it down. It is a wickedly ugly cycle.
posted by AlexiaSky at 1:02 PM on September 2, 2016 [17 favorites]


I do think BPD is treatible, but that the majority of people subjected to BPD treatment aren't actually candidates because they are misdiagnosed.
posted by AlexiaSky at 1:05 PM on September 2, 2016 [4 favorites]


I can't really respond due to sheer anger about the misdiagnosis. Let's just say I only started getting better when I rejected this diagnosis and found a therapist who actually asked me for the stories behind why I behave this way. The medical part of the mental health system insists this is me. Anyone with a backing in trauma says I'm so not this and hey when we listen to your life story it makes sense why you run away from help and don't trust others ( not including factors like my abusers used medical things to scare me). Somehow it doesn't make sense to the shrink that I'm wary of him when the paper they make you read when hospitalized says you have no right to refuse treatment. Cause nothing makes a trauma victim feel safer than someone else having complete control over their body.

I believe BPD exists and is treatable but I also believe that every single woman I know who has had complex trauma gets it stuck to them once they don't get immediately better with meds or in CBT. It's a damaging label to be misdiagnosed with in more ways than one. My Celiac disease and chronic pain has been blamed on having BPD. attention seeking. The medical community defines me as that and tells me to not talk about my trauma and will forever. I fully expect that I'll end up dead from cancer because of the dismissive tones from doctors as soon as they see that in the chart.

OK. Did have more to say than I thought. Being applied to trauma victims with no attempt to treat their trauma is further victimization and silencing.
posted by kanata at 1:23 PM on September 2, 2016 [29 favorites]


Oh and it is amazing how they all say I'm stabilizing and doing better with less "instability of emotions" and it occurred the same time I moved away from abusive family and on my own.
posted by kanata at 1:26 PM on September 2, 2016 [10 favorites]


Hasn't sexism long been an issue with the BPD diagnosis? I remember it being a big part of the classroom discussion of Girl, Interrupted when we read it in high school English way back at the turn of the century.
posted by indubitable at 1:28 PM on September 2, 2016 [4 favorites]


Sexism has been an issue for BPD and Histrionic Personality Disorder pretty much since they were instituted. I personally know someone misdiagnosed with BPD for reasons of, essentially, misogyny from an asshole psychiatrist who had this misdiagnosis cost $1000, because ten years later they had to pass through a process which required a medical evaluation that might have rejected them on basis of BPD (it's incurable, after all!) and so they had to pay out-of-pocket for a specialist evaluation from a psych who basically said "Wow, you do not have this thing. Wow."

This shit is, by the way, why I'm very uncomfortable with the tendency to immediately label abusive people or people who are behaving poorly as narcissists. I don't really like dealing with the PDs because I am so keenly uncomfortable with the tendency people have to use them to just... permanently write people off completely.
posted by sciatrix at 2:04 PM on September 2, 2016 [25 favorites]


You know what stood out to me? "Fear of imagined or real abandonment", in a world where many women, for a very long time, have been dependent on men for survival.

If a man is paying all your bills, then you HAVE to be constantly watching for signs that he might not pay your bills tomorrow, that you might be out on the street. That's not crazy, that's totally rational.

And "alternates between idealizing and devaluing"? How exactly do we define that in a world where people often feel free to treat women like shit and assume the normal thing is to just "get over it"?
posted by corb at 2:19 PM on September 2, 2016 [36 favorites]


I have a friend with a BPD diagnosis. I have a bipolar diagnosis. We've both had a really, really similar time illness-wise - pattern, severity, age of onset, other comorbidities. I think the difference in our diagnoses came about as a result of a bunch of relatively small factors: I'm a little more compliant as a patient and a little more rigid/controlling over how I come across in doctor situations, her symptoms have been a little worse overall, and I've been somewhat less open with the doctors I've seen about some of the self-destructive behaviours (self harm, disordered eating etc.) that she's been a little more open about.

Otherwise it's been so similar that it feels like we clearly have the same thing wrong with us. Only there's a different name for it if you're a woman who's perceived as being more difficult.

Diagnosis has always felt like a rigged game you have to play to get an end result that might (possibly) be helpful. I figured mood stabilisers might be more helpful to me than the SSRIs that were clearly making things worse, but it took years of being told that what I was experiencing as mania couldn't possibly be mania because it didn't fit the doctor's personal concept of mania, having my symptoms dismissed and being misprescribed a ton of unhelpful medication to finally get the label that unlocked access to treatment that was actually helpful. Even though the thing that was wrong with me had not changed at all in that time.

It's like the older, more rigid criteria for eating disorder diagnosis, which missed a vast amount of people (and thus limited their access to treatment) just because their experience didn't match whatever the person who wrote the textbook thought was important.

Treat the symptoms, don't worry so much about rigidly defining the boxes.
posted by terretu at 2:44 PM on September 2, 2016 [9 favorites]


My oldest has a BPD diagnosis. They feel it fits them, but I'm not convinced. Before they came to us, they had been abused and repeatedly abandoned by their family; they were then removed from their college on short notice after a mental health crisis. I question whether BPD is its own diagnosis separate from PTSD and from the other effects of abuse and neglect, and, like the person up-thread who lets people stay in the spare room, I've watched my oldest make incredible progress in the time they've been with us. Having a home they won't be cast out of, good psychological care, good health care, for the first time in their life is making a huge difference, as well as the conscious work they're doing.

We finalized the adoption on August 10, by the way. And today my oldest got a letter from the White House congratulating them on their new family and wishing them well. It was awesome. They don't have a checkbox on the White House website for "a legal adult being adopted," and whatever minion correctly parsed my email and got the right variation of the form letter in shape has my eternal gratitude.
posted by not that girl at 3:34 PM on September 2, 2016 [34 favorites]


Also, living as I do in a house with a spare room sometimes filled by a friend or an acquaintance, I have noticed that for many people, what seem like severe, intractable borderline/inappropriate affect/weirdness-type mental health issues improve out of all recognition after a few weeks of sleeping in a clean, appropriately heated and cooled room with a real bed and a door that can be closed.


Frowner, I just wanna thank you for doing God's work.
posted by tel3path at 3:40 PM on September 2, 2016 [22 favorites]


Frowner, I just wanna thank you for doing God's work.

I should say that I am not always gracious about it, my house is literally a crumbling Victorian, there is little fridge space for guests and sometimes we all stress each other out.

One other thing in case other people think of inviting folks to stay with them: be prepared that you can get perfectly normal housemate burnout, and be prepared for the fact that sometimes when people have been struggling they are not always the best housemates. If you know those things going in, you can just accept that it won't be like a sit-com all the time. I am fortunate in that all the folks who have stayed with me have actually been good about the big stuff of living together so most of the stressors have been that the kitchen is small, there's one bathroom and four adults are just a little bit much in that regard.

Also, people may need to stay longer than anticipated, or they may think that they can chip in for rent or help out extra with chores and then not be able to do so. I think it's important to invite people to stay with the baseline setting of "we will all not drive each other into fits of frustration all the time; anything better than that is gravy".

But there's a plus, really - I always feel better knowing that someone is home if anything goes wrong. You would be surprised by how nice this is if you have not experienced it.
posted by Frowner at 3:52 PM on September 2, 2016 [25 favorites]


I've been having a lot of thought about the relationship between BPD and C-PTSD lately. I have a friend who seems very BPD (but is also a white dude, and in the US, so there is no diagnosis and unless health care is fixed, will never be one) but the more I looked at how to be friends with people who have BPD, the more it looks like C-PTSD than anything else.

Like, you were horribly emotionally abused as a child, so when someone you love is angry with you no matter the reason it seems fairly straight-forward that you get triggered, right? I have 'normal' PTSD so I know that state and I know how hard it is to deal with it and react well and cope. Except instead of being something 'normal' like a loud noise, or depictions of sexual assault, or even something strange like exposed brickwork, you get something totally fucking mandatory to human relationships like 'you hurt my feelings and I am upset' or 'I don't like a thing you like' and when it happens you're drowned in a vortex of fear and loathing? Maybe not every time but I know I am a lot better with triggers the more my symptoms are dealt with, but if you don't know what's happening how do you deal with it?

It just breaks my heart, this whole thing. And it doesn't surprise me that it's so disproportionately applied to women as well, in spite of more men having those symptoms and behaviours. Women might get a wider range of emotions we are allowed and expected to have, but god knows they're all wrong.
posted by geek anachronism at 4:47 PM on September 2, 2016 [21 favorites]


As someone whose personal and family history has kept me in close contact with the world of psychiatry, I've met a few people with a BPD diagnosis. I suspect that all of them would have been better served by having their parents, guardians or partners diagnosed as abusive narcissists instead.
posted by [expletive deleted] at 5:19 PM on September 2, 2016 [11 favorites]


I've had the same psychiatrist attempt to diagnose me with BPD twice. (A few years ago when I had a raging case of post-partum depression, and more recently when my family doc wanted me to rule out a psychiatric cause for my bone-crushing fatigue.)
This based on my filling out of the mental states survey alone. No interview, no follow-up, just: enter office, scan over paperwork, fix me with a condescending glare and regretfully inform me that I most likely have BPD and should therefore never take SSRIs because they will cause a psychotic break. End of appointment.
This last time, I laughed at him, told him he was wrong both times, and that I had successfully taken a course of SSRIS for my PPD with no need for help or hindrance from him. He took this resistance as further evidence of my supposed mental lability, and he was QUITE pissed off that I hadn't had the forewarned psychotic break while on Zoloft.

I am going to make a pretty good guess that he doesn't pull this kind of shit with male patients.
posted by bluebelle at 6:48 PM on September 2, 2016 [11 favorites]


I got sent to a psychiatrist to investigate tiredness and inability to focus too (which turned out to have an entirely physical cause, easily fixed). MY GP thought maybe I had some kind of ADD I guess and sent me. The psychiatrist decided I was bipolar the minute I walked in the door, apparently because I was a high achieving young female researcher and apparently you can't be bright and young and female unless you are manic. I am not bipolar, at all. I have none of the symptoms, not one: I am a very measured person. If anything I'm a bit boring. Did not stop this guy one bit, he expounded for our three sessions on how I was wrong and he was right and prescribed like 7 different drugs, none of which I took of course. I kept going back because it was like an alternate reality experiment and also my friends demanded I did so they could hear about it after.

I went back to the GP a month or so later and told her the guy had prescribed me lithium, seroquel and some sleeping pill I don't remember during the first session, and more drugs subsequently and she was goggle eyed. I think she was mostly pissed that he didn't listen to her though, not that he was a madman with a prescription pad who had OTHER PATIENTS. I did report him but he still practices so it did no good. Oh, and btw you're anemic, take this and you'll be fine.

I don't trust that profession at all anymore obviously. imho, psychiatry should only be practiced in a structured setting with lots of oversight and double checking by colleagues and strict reporting requirements. It seemed so ripe for abuse.
posted by fshgrl at 8:25 PM on September 2, 2016 [16 favorites]


This kind of asymmetry makes me so nervous. I guess I identify as transfeminine and I've had the experience of being forced unwillingly into therapy (I was a minor), and the whole time I felt on guard about what kind of diagnosis I might be conveying to the psychologist. So I lied to get out of his office as quickly as I could, and I'm not sure I regret it. Even now where I think I could probably benefit from counselling in relation to my depression, anxiety and dysphoria I am super cautious about approaching anyone, because of precisely this issue (I've done some digging and I think I've found someone reliable, fingers crossed). The DSM is not without merit, but there's a lot of guesswork in there and a tonne of scope for psychologist bias to creep in. It bothers me a LOT that this isn't more widely acknowledged by clinicians, because their undergrad cognitive psychology classes should certainly have covered reasoning and decision making biases: sometimes I wonder whether they even listened to their lecturers.
posted by langtonsant at 8:28 PM on September 2, 2016 [1 favorite]


The institution of psychiatry and psychology are so married to patriarchy and classism and patronizing assumptions about fellow humans that I think we need to just burn down the framework and rethink everything.

Yes. People need to understand a very simple thing: mainstream psychiatry (and often psychology as well) serves power. It imbues subjective judgments about deviation from social norms with a false medical authority, it ignores trauma, it radically disempowers people by decontextualizing their problems and locating the ultimate source of their distress in their biology, it labels people with essentializing and stigmatizing "diagnoses" — which are really just stereotypes, and fundamentally it has a cartoonishly naive and damaging understanding of what it is to be a human being.

Burn it down. There are better ways to help people.
posted by Wemmick at 11:44 PM on September 2, 2016 [8 favorites]


Is there a way to get a PDF without logging in?
posted by M. at 12:21 AM on September 3, 2016


There are definitely people who are very mentaly ill and lots of great doctors who provide life saving care but right now the system for finding one seems to be buyer beware. Which, y'know, the buyers are not in their best frame of mind. It's kind of a terrible system.
posted by fshgrl at 12:34 AM on September 3, 2016 [1 favorite]


Pretty much every single "treatment"--even drugs-- I've ever seen for mental illness is victim-blaming. It's so, so gross. If you're hurt, there's something wrong with YOU, not the person who hurt you. You're thinking wrong, your emotions are wrong, but there's nothing wrong with whoever hurt you because they're happy. It's fucked up.
posted by Violet Hour at 1:49 AM on September 3, 2016 [4 favorites]


Given this concern to protect theintegrity and individuality of persons who have been given this label, I will not use “borderline”as a pronoun,

What does he mean, "as a pronoun"?
posted by amtho at 4:13 AM on September 3, 2016


This seems like the right thread to recommend Borderline by Mishell Baker - the author has the diagnosis and wrote a searing urban fantasy novel with a protagonist with not-super-well-treated BPD, and it's really great. (Mishell is a recent acquaintance of mine, and she is *awesome* and talks on Twitter a lot about her management of her BPD.)

I have several friends with that diagnosis (all female, of course) and complex PTSD seems like a more congruent way to describe it in I think all of their cases. I have started to get pretty seriously annoyed on their behalf by the way borderline is often described as a untreatable life sentence.
posted by restless_nomad at 10:41 AM on September 3, 2016 [3 favorites]


the more I looked at how to be friends with people who have BPD, the more it looks like C-PTSD than anything else.

This feels true to me, as well, as someone who does diagnose people professionally. I think the diagnosis of BPD is really just an attempt to describe certain behaviors, most of which are completely understandable to reactions to extensive ongoing trauma. And I have been very happy over the years to see the (not-at-all-complete) shift in understanding of BPD and other personality disorders as treatable conditions.

The label of BPD or "borderline," however, is often used to marginalize, pathologize, and otherwise hurt women and other people from already marginalized groups. Who are often more likely to be survivors of extensive ongoing traumas, and more likely to be gaslit about those traumas and policed about their reactions to those traumas, which means more likely to develop coping skills that look like BPD.... there's a nasty vicious cycle.
posted by lazuli at 1:08 PM on September 3, 2016 [6 favorites]


And while I'm totally on-board with the idea that people have, and still do, throw out "borderline" labels as a political act of marginalization, I think the linked article is a mess. It's absolutely a problem that individuals experience mental-health issues due to societal dysfunction, and it's absolutely an ethical imperative to fix the societal dysfunctions, but we also need to be able to help the individual sitting in front of us without just saying, "Welp, guess you'll just have to suffer until we get that whole misogyny thing eliminated." Diagnostic categories are helpful in figuring out how to help the individual who is suffering. We can say, "Yes, it makes sense this person engages in these behaviors and has these fears, due to our fucked-up society and the fucked-up things that happened to her, and it's not really her fault," while simultaneously saying, "And we need to help her find ways to stop the relationship-destroying and life-threatening behaviors she's engaging in." Stopping after the first sentence is just cruelty.
posted by lazuli at 1:43 PM on September 3, 2016 [9 favorites]


What does he mean, "as a pronoun"?

I think he may mean in a nominal function (as a pronoun, or as a noun), as opposed to being used as an adjective or adverb, which only qualifies? As in, the difference between categorizing you and just describing one of your characteristics.
posted by ipsative at 1:52 PM on September 3, 2016 [1 favorite]


One reason BPD is so demonized is that it's a common diagnosis of abusers. Their victims will hear plenty of normalizing from parents, relatives, and bystanders. She's your mother, she's just overprotective. Be quiet, you'll set her off. Don't you know how much it hurts her when you don't call? Childhood abuse victims already have to re-learn what it means to have normal relationships, normal boundaries, normal arguments to avoid falling into the cycle of abuse themselves. Scholarly BPD denialism adds to a lifetime of socialization that these behaviors are on the normal spectrum of what it means to be a woman. To me, it's akin to denying that alcoholism is real because people are more likely to blame drunk women for their behavior than drunk men.

The article also fails to address the connection between NPD in males and BPD in females. I'm sure as we learn more about mental health, we'll find some of these diagnoses are closer to a spectrum than distinct categories.

I have a good deal of sympathy for those misdiagnosed, and who have been lead to believe they are hopeless and untreatable. Seeking help, seeking the right therapist, and seeking the right treatment for you, regardless of labels, is very brave and proof that you are neither monstrous nor irredeemable.
posted by Gable Oak at 3:41 PM on September 3, 2016 [6 favorites]


The most horrible experience I had as a student nurse was around labeling a woman percieved as "difficult" by a misogynist psychiatrist, and I've never forgotten it. I probably will never forget it as long as I live.

I was on a clinical placement for three weeks in an acute inpatient mental health unit. As students we were mostly there to shadow nurses and talk to the patients staying there. There was one woman in her 40s I connected with enough to ask her if it would be okay if I did my required health assessment on her. She said ok. As I'm taking her history I'm hearing the most horrific shit I have ever heard - sexual abuse from a young age perpetrated by multiple family members, the ongoing issues she'd had after that with foster care, relationships, housing, holding down a job, other healthcare problems. I thanked her for helping me out, and when I went home that night I cried and cried.

The next day I got to sit in on the multidisciplinary meeting that happened once a week between the psychiatrist in charge, the resident doctors, the charge nurse, etc. It had happened that the previous night one of the other patients had made sexually threatening comments to a group of the female patients, which included the lady I had done my health assessment on. As can be imagined she was completely re-traumatized by this, felt unsafe in the unit, requested to have a staff member sit outside her door that night, and was on the verge of self-discharging.

So the psychiatrist pipes up and starts talking about how this woman was attention seeking, and was well known to be borderline. She has BPD, she has BPD, he just keeps repeating this in the most dismissive way you can imagine, like almost sneering it. Bluntly says she's being hysterical and dramatic.

Here's the thing - this lady did not have a diagnosis of BPD. ANYWHERE. On her medical chart, or in her history or any place. And she was actually from a different area so this was the first time she had ever interacted with the local health system. So the point being, this psychiatrist was not familiar with her, had only met her a few days before, and had apparently decided to pull this diagnosis out of fucking thin air. I know because as I sat in the MDT meeting I felt so stupid for having missed her diagnosis of BPD that later that day I combed through all of her medical records trying to figure out where it was documented and how I could have overlooked this. And came up with nada.

Luckily this patient wound up getting transferred back to her own local area the next day to continue her treatment, where ostensibly they knew her better and weren't grossly incompetent. But I have never forgotten that incident and I now view every single diagnosis of BPD with extreme suspicion. I feel like there is so much mislabeling of women with physical or mental health problems as being hysterical or anxious or whatever that we should completely overhaul the way women are triaged within the health system. To me rather than assuming anxiety or depression or a personality disorder and working backwards, instead every other possible cause should be eliminated first before we break out these (very often gendered) diagnoses. The reality is we all work in a sexist system and that's not going to change until we start changing our practice. Not mislabeling women from the get-go and then prejudicing their healthcare from that point on would be a great fucking start.
posted by supercrayon at 4:03 PM on September 3, 2016 [23 favorites]


From my experience in non-clinical, administrative meeting rooms (as opposed to a clinical unit that provides care... I'm never on a unit seeing care) reference to BPD is short-hand for everyone (especially clinicians) to shake their heads, sigh exasperatedly, eye roll, groan, or huff.

Not once--not ONCE--have I heard anyone say, "oh that poor patient"

(maybe that happens with clinicians behind closed doors, or perhaps with the patient)

I've seen it used as an explanation for why someone acted out or was treated poorly, or why someone was complaining or put in seclusion... not as a starting point. Once you say BPD in a hospital, it shuts down so much dialogue around care... I feel like that's a problem.
posted by Dressed to Kill at 7:00 AM on September 4, 2016 [2 favorites]


Right. While I'm sympathetic to the whole "here's a shorthand for a constellation of issues, here's how we treat them and improve them" concept--and psychiatry does have diagnoses that really work like that!--I'm not actually sure that the PDs are part of those diagnoses. Rather, I see them discussed and described not as constellations of problematic behaviors caused by toxic unspoken beliefs that can be treated and improved with therapy, but as inborn personality traits that are intrinsic to a person's self and cannot be fixed or changed. Medical professionals seem to just... take them as a sign that a person's particular issues are immutable and not worth trying to fix, and instead just work around them. In fact, in every psych course I've taken has explicitly taught the axis II disorders that way.

That's my problem with them as diagnostic categories. They're shorthands that come without any treatment plan or even a method of improving patient quality of life attached. And for that reason, I think they should either be abolished or replaced with something that does come with a method of therapy attached.
posted by sciatrix at 11:36 AM on September 4, 2016 [3 favorites]


Yes, but that's changing, mainly I think due to DBT, which was designed to treat BPD (there are other protocols, but I think DBT's existence spurred their development). The idea that personality disorders are treatable is definitely out there, but it's new, and the profession's resistant to change. I don't think that means BPD doesn't exist, though, if that makes sense.

(I think I was very lucky in my own training to have attended a lecture about treating personality disorders, which included the idea that they are cureable!, early in my training as a therapist. So that's been the assumption I've always worked under. I get that it's not yet the dominant assumption in the profession.)
posted by lazuli at 11:43 AM on September 4, 2016 [2 favorites]


Yeaaaaaah, my experience has been that it's not even that it's not the dominant assumption, it's that it's really quite a rare one--especially to people who have been out of training for a while. I suppose the only way to spur improvements is to yell that DBT is a thing at pretty much every mental health professional who looks at the academy for the next twenty years. As it is, though, the legacy of BPD in particular is so damn poisoned... :/

It's also the thing that makes me deeply worried about the popularization of the term "narcissist" on the internets. I'd rather label abusive people abusive, which is a behavior and anyway is the thing we are generally concerned about when discussing them, than label them as NPD or BPD. I get that it's an important thing for many people, as part of a disentangling process, to be able to say "this person who has abused me is unsalvageable from my perspective, and I need to stop investing all my effort into trying to magically be the Perfect Child/Good-Enough Partner/Best Employee/whatever part of the sick system you share with an abuser" and then run.

But I also think that it's really hard for many people who are trying to cut free of an abusive dynamic to write the other person off as inherently unsaveable, and I think that framing it as "this relationship is abusive to me and I need to cut the rope" is a more.... hm, accessible concept for the person who needs to disentangle than the concept of selfish, unsaveable people who are Just Plain Bad is. (Which is how I see NPD portrayed, to be honest, along with other PDs like BPD and APD.) I also think it's more realistic, but that's almost beside the point. YMMV, though.
posted by sciatrix at 12:00 PM on September 4, 2016 [2 favorites]


I should say, too, that I work with a client population that includes a lot of people with personality disorders, so I definitely see, firsthand, everything that everyone is talking about: the dismissal that comes from a lot of clinicians, the trauma histories that almost invariably have contributed in major ways to the clients' unhelpful and counterproductive (now) behaviors, the clients' suffering, and the way that skillful clinical intervention can help. And it's important to remember that "skillful clinical intervention" can and should include environmental interventions, like helping a client figure out how to get out of abusive or traumatizing living situations and relationships. That can just take a great deal of time, and it can be demoralizing for a client to realize they're going to need intensive intervention for years.

Recognizing the extent that past and current trauma can have on a client is also (unfortunately!!!) rather new in psychology/psychiatry, because (in my opinion) there's been such a backlash against Freudian ideas and toward behavioral ideas that the dominant idea became something like, "The past doesn't matter, focus only on the here and now," and I think we overcorrected away from Freudian ideas of the importance of childhood. As someone whose clinical training was almost exclusively with trauma survivors, I find it bizarre to go to these trainings and have trauma-informed care or the conclusions from the ACES study (where it turns out that traumatized kids often end up with psychological and medical challenges, and the more childhood trauma, the more challenges) presented as "new" or "revolutionary" ideas, but apparently they are to a lot of people. I'm also constantly astounded at the lack of understanding of what constitutes trauma (and got into a slamming-down-the-phone shouting-match with a clinician who couldn't figure out why hospitalizing a client against her will would have any downsides); I suspect we're going to start seeing wider understanding that societal misogyny, racism, homophobia, transphobia, etc. are traumatic ongoing events that cause major psychological and medical problems all on their own. I think as those understandings grow, the way we conceptualized "mental illness" is going to keep shifting, too.
posted by lazuli at 7:41 AM on September 5, 2016 [6 favorites]


But I also think that it's really hard for many people who are trying to cut free of an abusive dynamic to write the other person off as inherently unsaveable, and I think that framing it as "this relationship is abusive to me and I need to cut the rope" is a more.... hm, accessible concept for the person who needs to disentangle than the concept of selfish, unsaveable people who are Just Plain Bad is. (Which is how I see NPD portrayed, to be honest, along with other PDs like BPD and APD.) I also think it's more realistic, but that's almost beside the point. YMMV, though.

Definitely, and it can -- and often, in my experience, almost always does -- also work the other way, with people unwilling to disentangle from someone who's dealing with mental illness (rather than just plain evil). I suspect some of the framing you're talking about is people trying to come to terms with their own co-dependency, almost -- after having spent years being overly lenient and overly accommodating to the person because they're "sick," they can swing the pendulum too far into "No, they're evil." Healthy development would then try to find the more realistic middle ground, but sometimes people don't get there (and I think most of them need to go through the anger first, and sometimes there's just so much anger that it takes a looooong time to go through).
posted by lazuli at 7:46 AM on September 5, 2016 [2 favorites]


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