BORDERLINE: The Biography of a Personality Disorder by Alexander Kriss, PhD. This is an informative read regarding the history of this illness, along with hysteria and how BPD and its formation in the literature has evolved over time. 

My favorite excerpts from the book are below: 

The Hippocratics posited that a great many symptoms reported by women – from epileptic like seizures to stomach pain to the feeling of being choked- resulted from her uterus wandering about her body. 

This anatomical focus was unusual for the Hippocratics and a betrayal of their empirical philosophy: we know they never observed a womb moving about someone’s body because we know womb’s don’t actually do that. Yet this theory helped to explain any vexing symptom an ancient Greek woman might present to an unfailingly male physician, as he could attribute her various experiences to her womb having roamed to various places. 

“What they’re being subjected to now will change how they see themselves and the world. Those changes might take them down paths they wouldn’t have otherwise traveled. As adults they will be who they are, in part, because they lived through these experiences. 

Neither was it considered overstepping for a Hippocratic physician to treat his female patient’s illness by recommending that she marry and have sex with a man. 

A shift away from splitting according to anatomy began in the second century CE, when the physician Galen of Pergamon took up the task of merging medical knowledge with metaphysical questions of the soul- launching, in essence, the field of mental health. 

Advances in anatomy and physiology led Galen to reject a wandering womb as the de facto explanation for female illness. Galen viewed the failure to regularly engage in the “release” of sexual intercourse, rather than a nomadic organ, as the cause of female illness. In these cases Galen advocated for many of the same treatments found in the Hippocratic corpus, including the prescription of sex and marriage. While there is limited evidence that he healed women with greater success than the Hippocratics, it is abundantly clear that Galen’s theory of hysterical phenomena- that a woman’s dysregulated internal “passion” led to bizarre and, at times, serious illness- informed his theory of “metaphysical disorder”, or what we now call mental illness. 

Yet Galen was also bound by the social values of his day and the hierarchies of male supremacy and slave ownership.

 With respect to women, Galen espoused the mainstream perspective of their inferiority to men. Passion existed in men and women alike, but women- being of softer flesh and weaker nature- were more prone to both physical and metaphysical illness. Galen saw the ideal therapist as male and preferably advanced in age- to ensure that time and wisdom have freed him from passions thrall- and the talking cure was presumed to be useful only for grown, free men seeking to improve themselves. When it came to matters of the soul, women were a lost cause. “Untamed horses”, Galen wrote, “are useless”. 

Displays of excess emotion, sexuality, or physical fits- all historically associated with hysterical conditions- were grounds for suspecting witchcraft, but at the same time, a woman not showing adequate emotional upset during her trial was also considered verification of her being possessed. So began a 300-year crusade against women. One record from 1586 reported a visit by inquisitors  to a cluster of German villages; by the time they departed, all but two women had been tried, convicted, and murdered. Men, too, were persecuted if they displayed hysterical symptoms or showed sympathy toward accused women. Identifying the ill and isolating them from the well- through public shaming, torture, or execution- overtook any priority the church had ever placed on relieving people of suffering .

The issue, it seemed, was not that hysteria preferred women over men, but that Physicians preferred to call it something different depending on the gender of the patient. men tended to be labeled as hypochondriacs- another new and poorly defined term of the era- while women were overwhelmingly called hysterics.

 Still other doctors  channeled their rage at hysterical patients through the act of healing itself. One London Doctor, W. Tyler Smith in 1848 gleefully reported about his program of “ injections of ice water into the rectum, introduction of ice into the vagina, and leeching of the labia and cervix.” He noted with something approaching wonder how quickly the leeches sated themselves.

 English physician James Cowles Prichard coined the term in 1835. He wrote one of the first recognizable ancestors of the modern BPD diagnosis: the morally insane were often educated models of civility, he stated, and yet struck by “ morbid perversions of the feelings”  so strong that they bled into patient’s behavior, defying social norms and risking confinement to an asylum. On paper, these individuals led respectable lives. In reality, they fought, fornicated, and spent recklessly; they provoked great distress and close friends when their affirmations of love turned suddenly to declarations of hatred.

Freud’s repetition compulsion theory goes that we are driven to recreate that which has overpowered us in the past, to prove to ourselves that we have mastered it’s conditions. This drive operates without- and sometimes directly against- conscious intent, and often serves to re-traumatize or pass trauma on to others.

I emphasize the aspects of BPD:  pervasive feelings of emptiness, the use of splitting to organize views of themselves and others, the tendency toward impulsive, often self-destructive action when faced with overwhelming emotion. The condition as I understood it was connected to chronic experiences of trauma or abuse starting from an early age. 

Women represented, of course, the bulk of the patients Freud was attempting to understand when he turned his attention to hysteria, and his description of them as “ semi-barbaric”  was consistent with how he considered them in general:  inferior, belonging and domestic roles that supported the intellectual, patriarchal bourgeois society of Freud’s day.

If a patient was overly excitable, she was given a sedative; if she was overly sedate, she was subjected to electric shocks or ice baths to activate her body. If symptoms went away, she was declared “ cured”; when they returned, the same ineffective treatments were trotted out again.

Hysteria emerged, Freud said, from the repression of memories of sexual abuse. 

Freud’s own traumatic memories, autobiographical writings, and letters refer to a childhood marked by various sexual imbroglios  and violations: his father’s multiple marriages;  suspicions of incest between his mother and his half-brother;  possible hysterical illness in at least one of his sisters;  an allusion to his childhood nursemaid acting as his own “ teacher in sexual matters”. 

In therapy with borderline patients there often comes a time when an explicit conversation about this word is needed, to make clear that abandonment is a very particular kind of loss. It is loss without warning, without context, and without end; it is traumatic loss, loss that disrupts a fundamental sense of safety, of reality. 

The history of BPD itself now splits in two. One path is bathed in light: the history of psychoanalysis’s meteoric rise, in the course of which, paradoxically, hysteria would recede into shadow. We will first follow that more public, visible path of success embodied by Freud, before considering the path that ran parallel to it, underground, embodied by his colleague Sandor Ferenczi. 

By the end of the 1910s he began to move in pursuit of something beyond the treatment of any disorder, toward a comprehensive theory of the human condition. His 1923 paper “ the ego and the ID”  not only introduced some of Freud’s most recognizable terms- id, ego, and superego- but fundamentally reframed psychoanalysis from a form of therapy to a method of explaining human behavior in all its forms.

The radical- conservative tension within Freud would not abate;  he was, for the rest of his life, to be defined by this contradiction. He sought truth, yet obscured his own. He exposed the oppressive effect of mainstream society on individuals, yet wanted to become mainstream himself.

 He showed vulnerability, publishing his dreams and fantasies- even his failed treatments- for the world to see, yet he also insisted that his personal experiences were universal, refusing to consider the uniqueness of his own ( or anyone’s)  psychology or history. Freud reacted fiercely to any criticism that even hinted that his ideas were products of his idiosyncrasies- he refused to be seen as anything but objective. 

Trauma is not so much an event that happens to us as it is our reaction to that event. It’s what we call the destruction of our established reality, an event that breaks the rules we’ve come to expect our environments to follow.

Freud did the world a great service by dragging the murky unconscious into the light, and a great disservice by burying reality in darkness. 

The fear of abandonment is, really, the fear of being forgotten. of no longer existing in the mind of others and therefore no longer existing at all.

 We cannot experience and reflect at the same time. 

Sandor Ferenczi was the kind of genius history tends to forget. His compassion for human suffering was destined to flail in the rapid current of Freud’s psychoanalysis or any mainstream cultural movement. Unlike Freud, Ferenczins championed social reform, advocating for the legalization of homosexuality and the civil rights of sex workers. 

Ferenczi ,on the other hand, never stopped questioning who he was, what he believed, and why. He was the shadow-Freud, unwitting progenitor of the underground path of BPD to which hysteria was relegated.

As mainstream psychoanalysis was moving away from its focus on female hysteria, the issue of male hysteria suddenly re-emerged.

 The Great War, which began in 1914, posed a more particular threat to Freud’s movement, in the form of a new kind of illness. As wounded soldiers returned home, veterans’ hospitals were overwhelmed by cases of “war neurosis”: men who’d gone to war of sound mind and return shaken and enfeebled, suffering from nervous attacks, violent outburst, nightmares, and physical complaints of no obvious medical origin. If psychoanalysis were to justify its ambitions for medical authority, then it would need to be able to explain what was happening to these men. 

Charles Samuel Myers, a British physician, referred to these veterans as suffering from “shell shock”. The Psychological Society was an academic group whose members had little interest or experience in treating emotional illness; they concluded, to Myers’s frustration, that shell shock was a regrettable, incurable consequence of war. 

Ferenczi identified cases of war neurosis that would, during the next Global war, be called “combat stress”, and would today be labeled as post-traumatic stress: men whose psyches appeared to have been shattered by the horrors witnessed on the front lines.

In 1932, Ferenczi  began by reiterating his newfound perspective: trauma was a part of psychological illness, and if the illness was common that meant trauma was common too.

The event itself was not what we meant by trauma. It was the inner experience of being the target of that seduction that lay at the heart of hysteria and war neurosis, perhaps all dramatic illness, perhaps most of human suffering:  confusion.

The pain becomes so overwhelming that the child abandons herself completely. In her mind she can find only confusion and so, “completely oblivious of herself, she identifies herself with the aggressor”. She learns to see herself through his eyes, to see the violence as love, the disgust and guilt as her own- that she, not him, is wretched; that she is to blame.

After Ferenczi’s death in 1933, Freud embarked on an insidious campaign to discredit his friend’s work and minimize its influence on psychoanalysis. He falsely suggested that their views had been perfectly aligned for decades, dissuading close reading of Ferenczi’s published papers and in particular dismissing later writings as a product of the Hungarian’s failing health and deteriorating thoughts. In 1957, psychoanalyst Ernest Jones would solidify this narrative and Freud’s official biography, writing that Ferenczi’s lethal anemia “undoubtedly exacerbated his latent psychotic trends”, and dismissing his ideas about trauma and confusion as the products of a bitter and delusional man, lashing out at a mentor who had only ever loved him. 

Hysteria metamorphosed into BPD through a series of identity crises.

The first crisis was the battle over Freud’s legacy.

“It is well known that a large group of patients fit frankly neither into the psychotic or into the psycho neurotic group, and that this borderline group of patients is extremely difficult to handle effectively by any psychotherapeutic  method”. These words were spoken in 1937 before the New York Psychoanalytic Society by Adolf Stern and mark the first use of the term borderline to denote those vexing patients who did not fit into psychiatry’s categories. 

Anna Freud’s The Ego and the Mechanisms of Defense was first published in German in 1936, as a practical guidebook that her father had never been able to produce amid his vast and contradictory writings. Much of the terminology found in Anna Freud’s book remains in popular culture today:” intellectualization”, “sublimation”, “reaction formation”, and “repression”. 

By the time Medical 203 had morphed and expanded to become the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I)  in 1952, written by a similar committee of physicians and published by the American Psychiatric Association, there was no longer a clear distinction between psychiatry and ego psychology in the United States. 

The DSM-I drew heavily from Medical 203 in dividing psychological illness into five subcategories. The first, psychotic disorders, demonstrated how pervasive the influence of ego psychology had become: illness that inpatient psychiatrists had long deemed as biological in nature and that analysts had long deemed “unanalyzable” were now framed in the language of psychological compromise, as “a struggle for adjustment to internal and external stressors.”

Conditions that you would now be diagnosed as asthma, hypertension, or gastric ulcers- the biological basis of which were not well understood in 1950s America- were apt to be labeled mental illness. Psychoneurotic disorders included conditions like depression and phobias and were defined as illness arising out of the variable ways that an individual had learned to defend against anxiety. The DSM-I’s subclass, personality disorders, was both its most consequential and most inscrutable. It described people so set in their ways, so affixed to their defensive compromises, that they lived free of visible distress- opening the field of who might be considered ill to virtually anyone. Among the three listed subtypes of personality disorders, the first was “personality pattern disturbance”,  defined as “cardinal personality types, which can rarely if ever be altered in their inherent structures by any form of therapy”.  In this one fell swoop, psychiatry bestowed upon itself the authority to diagnose whom it pleased with a personality disorder, while absolving itself of the responsibility to provide effective treatment. The pattern disturbance group included, among others, the “ cyclothymic personality”,  marked by “ frequently alternating moods of elation and sadness”- a description of emotional dysregulation that would later be understood as a defining, and treatable, characteristic of BPD. The second subtype of personality disorder,  “personality trait disturbances”,  was defined as people who disintegrated under stress. 

The third type of personality disorder, “ sociopathic personality disturbance”,  explicitly assigned the “ill”  label to those who did not conform to mainstream society. Here one can find the codification of “ sexual deviation”  as a mental disorder, which named homosexuals and rapists, among other groups, as diagnostically indistinguishable from one another. addiction also appeared as a psychiatric label for the first time in this category, branding those who struggled with substance use as immoral- a stigma that has never gone away.

Lastly, the DSM-I Featured a fifth subclass for “transient situational personality disorders”,  a more formalized manifestation of shell shock or war neurosis, and the clearest antecedent to modern-day post-traumatic stress disorder. despite containing the word “ personality”,  these conditions were defined as being brought on by acute and severe stress, such as combat.

Rife with holes and contradictions, the DSM-I  was nonetheless widely adopted in America both by inpatient psychiatrists desperate for a formal system of diagnosing the institutionalized and by outpatient psychiatrists looking to expand the reach of their practice. 

The 1960s, the words of Adolf Stern, identifying a “border line group of patients”  that was “extremely difficult to handle effectively by any psychotherapeutic method”. 

Hungarian born ego psychologist David Rapaport, and is hugely influential 1968 textbook Diagnostic Psychological Testing, dubbed this vexing group “ preschizophrenic”. 

The start of Kernberg’s landmark 1975 book Borderline Conditions and Pathological Narcissism– a culmination of his work throughout the 1960s and early ’70s, and without question the most widely read and cited psychoanalytic text on borderline phenomena- he offered a unifying concept through the revised label of “ borderline personality organization”.  The prevailing psychoanalytic view of personality was that all people organize themselves over the course of childhood and adolescence around certain principles- around drives, around anxieties, and around the defensive compromises that negotiate between them. The borderline personality, Kernberg said, was no different. These individuals possessed a “ specific, stable, pathological personality organization”.  

All borderline cases were known to feature a diffuse sense of self. Such a patient, lacking a coherent sense of self, relied on defenses that originated from the point in her development when the self was inextricably tied to an object; namely the Mother. The patient split herself and those around her;  she projected her feelings out; she unconsciously constructed scenarios in which other people would feel and express the violent, churning emotions that she could not tolerate in herself. Her outwardly erratic presentation- she might shift from obsequiousness to a vicious rage; she might engage in dangerous behavior and then later Express a genuine conviction that she would never do such things; she might one day claim to hate the thing that yesterday she loved- was the result of her acting in accordance with this level of organization. 

Yet Kernberg avoided any consideration that a patient’s reliance on splitting might owe to developmental arrest, instead framing borderline illness as constitutional. Borderline patients tended to have a “history of extreme frustrations and intense aggression during the first few years of life”. 

His view complied with the “diathesis-stress model”  that American psychiatrists had largely adopted by the 1960s, which stated that mental illness of all kinds emerged when one’s genetic or temperamental makeup interacted with environmental catalysts. A version of this hypothesis exists today and has been validated by scientific research. There does seem to be a genetic predisposition to BPD, tantamount to a person being what we informally call “sensitive”-  that is, highly attuned and reactive to external stimulation. This innate quality makes the impact of a traumatic environment worse but is not in itself pathological. The environment does the heavy lifting and promoting a borderline organization within such an individual. Psychiatry in Kernberg’s day took the opposite view, regarding the environment as a nudge to someone born on the edge, nature determining far more than nurture. 

Kernburg countered that BPD’s needed to gradually understand that they could feel important in the eyes of another without violating the rules that applied to everyone else.

Sigmund Freud, who wrote about narcissism beginning in 1914 and highlighted its universal presence in human culture: the term itself, after all, dated back thousands of years to the ancient Greek myth of a young man, Narcissus, who fell in love with his own reflection. Kernberg used the term “ pathological narcissism”  to distinguish the more extreme version, and his behavioral descriptions of these cases would serve as the basis for present-day narcissistic personality disorder (NPD). 

The DSM-III defined BPD as the presence of at least 5 of the following symptoms in an individual: (1) impulsive behavior such as overspending, promiscuous sex, and shoplifting, (2) a pattern of unstable or volatile relationships, (3) “inappropriate” anger, (4) uncertainty with regard to identity, (5) mood instability, (6) the inability to be physically alone, (7) recurrent self-mutilating behaviors, whether accidental or deliberate, and (8) chronic feelings of emptiness or boredom. No meaningful revision to these criteria has occurred in subsequent editions. 

Histrionic personality disorder (HBD)- a term first coined by Alan Krohn in the 1970’s to capture his version of the contemporary hysteric- also appeared for the first time in the DSM-III. It overlapped with BPD to a perplexing degree. Narcissistic personality disorder also first appeared in the DSM-III, codified as the list of symptoms familiar to most people today: unique ones like grandiosity and the tendency to exploit others, as well as ones shared with BPD and HPD, such as excessive anger and “relationships that characteristically alternate between the extremes of over idealization and devaluation.” Insufficient data existed in 1980 regarding the gender breakdowns within these diagnostic categories, though by the DSM’s 5th edition the pattern was clear: 75% of NPD diagnoses were given to men and uncannily, 75% of BPD diagnoses were given to women. No edition of the DSM has dared broach the idea that these conditions represented two ways a person might resolve the same core problems according to the strictures of a sexist society.  

(From a Borderline patient): “I was a mystery to myself. I can’t explain how terrifying that feels. I wanted to die, At so many different times for so many different reasons… but I felt that I should know who I was before deciding to act. If I knew myself and still wanted to die, then I would know that I had tried. that it was a choice. but I felt I owed it to myself to wait. 

After the DSM III’s publication in 1980, there was an attempt to grapple with the borderline from a different school of thought; each ran into untouching parallels to the others. One shard concerned the case of Shirley Mason, born in 1923 in Minnesota. The details of her early life have been much debated, and there are few distinctive facts: we know that she was raised by strict Protestant parents; that her mother, described by a neighbor as “ witch-like”,  may or may not have been diagnosed with schizophrenia. We know that Mason, beginning in adolescence, suffered from episodes of intense emotional overwhelm and  disassociation. She met Dr. Cornelia Burwell Wilbur and according to her Mason would slip in and out of different “ selves”  at different times, shifts often catalyzed by stressful events. Each personality possessed its own name, disposition, and interest, and held limited knowledge of the other personalities or of Mason as a whole. 

A curious condition known as cyclothymic disorder was formalized to acknowledge the large number of patients who seem to show features of bipolar disorder- episodic peaks of mania and nadirs of depression- yet whose peaks never qualified as fully manic, nor the nadirs as fully depressive, with episodes that were often faster and blurrier than expected.

American psychologist Marsha Linehan would do all of this and more: she would draw from psychoanalysis, Christianity, and Buddhism while cleverly packaging these strands as compatible, even synonymous, with cognitive science. She would make BPD a household term and help shape our modern concept of mental health as something that can be taught through skills training and meditation apps. In 1987 Linean began publishing on a treatment that she;d developed, dialectical behavior therapy (DBT)- the first psychological treatment specifically created for people diagnosed with BPD. Defining DBT can be surprisingly difficult. It is marked by contradiction and paradox: a flexible theory executed through rigid technique; a structured approach marked by loose boundaries; a cognitive behavioral therapy that rejects basic assumptions of CBT; a compassionate and effective treatment that has helped to drive stigma for the past 30 years. 

At its core, DBT is rooted in Linehan’s belief that people with BPD are suffering from a “dialectical failure”-  that is, they cannot hold contradictory truths in mind at the same time. This was, in some ways, using new language to describe the old concept of splitting. Linehan  even used that word, noting that one of the major dialectics of life was appreciating that people have both positive and negative qualities, and that you cannot reduce things to all good or all bad without severely distorting your sense of reality. Linehan astutely pointed out that people with BPD often felt like they hated themselves, and in their hatred rendered personal change impossible. They were always trying to turn into someone else, to escape, and when they’re sudden and often extreme attempts at doing so- switching cities, jobs, friends, partners, adopting a new lifestyle or religion, giving up or taking up substances- inevitably receded and revealed that they were still themselves, they hated the new person they thought they had become. 

 “I have never been interested in borderline personality disorder as a ‘ disorder’ in itself,” Linehan wrote in her 2020 memoir, Building a Life Worth Living. “I have never targeted that. I target suicidal behavior, out of control behavior. I don’t think of myself as treating a disorder. I treat a set of behaviors that gets turned into a disorder by others. In many respects this was patently true, and we will see the origins and consequences of Linehan’s behavioral focus in short order. It is also true that she largely adopted the nomenclature of BPD in order to appease it’s psychiatric and psychological authorities that demanded adherence to names that could be found in the DSM-III. But, from the start, DBT was not only interested in behavior. Linehan also placed emotion, particularly the struggle to regulate emotion, at the center of BPD.

Emotion- the overflowing, unbounded discharge of raw psychic energy- lay at the heart of borderline experience. In fact, cognition played a relatively small role for patients who so often moved from unbearable feeling to impulsive action, seeming to skip over thought entirely. Linehan outlined a specific protocol that demanded a substantial buy-in from doctors and patients alike: to receive DBT one had to enroll in a comprehensive regimen of individual therapy, group therapy, and intermittent coaching sessions by phone. DBT therapy groups followed a prescribed curriculum with accompanying homework assignments; various protocols, especially around assessing and reducing suicidal thoughts and behaviors, had to be carried out in a particular way and at particular times. 

Without a doubt, much of DBT’s success- it is now the most prevalent treatment for BPD in the world, and by some metrics one of the most successfully evangelized psychotherapies of the modern era- can be attributed to how well Linehan played the game of research academia. But even if we poke holes in her empirical studies- or in the very notion of RCT’s as a useful way to measure things as complex as mental health and psychotherapy- it is hard to deny the value of certain DBT ideas once you’ve been exposed to them. Beyond its core concept of radical acceptance, DBT’s greatest innovation was the introduction of ancient concepts from Zen Buddhism into the psychotherapist repertoire. 

The titanic rise of interest in mindfulness over the last 20 years can be credited largely to Linehan, who systematized the holistic practice into concrete exercises that could be easily taught to therapists and in turn patients, exported to other therapies, and packaged into self-help books and ultimately smartphone apps. One can now often find Linehan’s signature across not only mental health settings but also executive training programs, acting classes, and various corners of the internet. Studies have shown that the mindfulness exercises of DBT- which focus on being present with, and accepting the transience of, thoughts, feelings, and bodily sensations- maybe the most effective way that the treatment helps patients learn to regulate emotions and, in turn, improve symptoms associated with BPD.

There is, however, another Legacy to Linehan’s work that is less positive. Even as some aspects of DBT, such as mindfulness exercises, have by now been branded as helpful to virtually everyone, her treatment simultaneously promoted an image of the borderline as dangerous and insane. Linehan’s  writing hinted at a deep compassion for those suffering with BPD, but that compassion was often inhibited by the dry language imposed on empirical researchers of her era. DBT therefore had to speak for itself, and its structure largely served to reinforce stereotypes and arguably, perpetuate the disorder itself. In strict DBT,  patients are seen by group and individual therapists and have permission to call their individual therapist at all hours, with the expectation that the call will be answered. Sections of Linehan’s DBT  manual, such as “ working out problems of staff splitting”  and “ keeping information confidential”,  were born from the problems that these aspects of her treatment created: patients had a staff to split only because DBT assumes patients need a whole team of people to keep them in check; therapists have a harder time maintaining client privilege when patients can contact them at any time, including when they are not at work, with little regard for professional boundaries. This is not the direction that treating BPD had been heading previously. Kernberg had seen the condition as something that a properly trained psychotherapist could work with one-on-one, but DBT suggested that BPD patients were so wild that only a team of experts, sharing the load and supporting one another, could possibly hope to bring a single one of them back from the brink. 

If you speak with anyone who is trained directly by Linehan, they will invariably define DBT as a treatment for the “chronically suicidal”.  This was always the language Linehan adopted- she saw the disorder, or the part of the disorder to be treated, in terms of how close the patient was at any given time to killing herself. This posed a problem from the start, as BPD patients frequently engaged in behaviors that looks suicidal but did not result in death, and often we’re not really life-threatening- superficially cutting their skin, taking enough pills to get sick but not nearly enough to be lethal. Epidemiological evidence emerging in the late 1990s and beyond suggested that despite Linehans contention that they lived forever on the brink, BPD patients were no more likely to kill themselves than other psychiatric populations, and actually less likely to do so than those with severe depression or schizophrenia. 

Linehan popularized the term “para suicidal” to capture patient behaviors that were violent but not deadly. Professionals Now call these behaviors “ non-suicidal self-injurious behaviors”  and colloquially they are often referred to as “self-harm”.  Contemporary research has consistently shown that there is no clear relationship between suicide and self harm- some people cut themselves regularly, say, but never attempt suicide; others attempt suicide with no history of self-harm. But Linehan  lumped them all together, enough to produce popular concepts of the borderline patient as one prone to make suicidal “ gestures”, or otherwise threatening bodily harm as a way to Garner attention. In truth, most BPD patients will tell you that, in the moment before they cut themselves, or punch himself in the face, or drink until they blacked out, they feel consumed by an intolerable emotional energy that cried out for release. They did not want to die, or really to do much of anything other than get the feeling out by any means necessary. 

Her Landmark 1991 paper, “ Cognitive Behavioral Treatment of Chronically Parasuicidal Borderline Patients,”  set the stage for DBT’s ascendancy and for how BPD would be understood by professionals in the public in the 21st century. 

Linehan was born in 1943 to a wealthy family in Tulsa, Oklahoma, the middle of six children. In her memoir, she portrayed her family as extremely mainstream: her oil executive father, a man of “ steel trap integrity”; her beautiful, church going mother; her athletic and socially popular siblings. They were so mainstream as to be, from her perspective, unequipped to understand Linehan’s  differences: her physical heaviness in a home where girls should be thin;her verbosity in a home where a girl should be seen and not heard. “If a person said something mean to me, my mother’s immediate response was to figure out how to change me so they would like me more”. Linehan’s  description of her adolescence is strange and disjointed. Despite being well liked and successful in school she reported being admitted as an inpatient to The Institute of Living in Hartford, Connecticut on April 30th 1961, a week shy of her 18th birthday, owing “ increased tension and social withdrawal”  and headaches. She was admitted for two weeks of diagnostic evaluation- but she would not leave the IOL for the next 25 months, re-entering free society only at the age of 20. Though she would not be formally diagnosed with BPD until years later, her years at IOL marked the start of her experiences as a patient that would profoundly inform her career as a doctor. She described her admission to IOL as a “descent into hell,” one of many illusions to Christian imagery that also would suffuse her later work. She had been separated from polite society, designated as ill and abnormal, and what followed was not unlike what would befall in 19th century hysterics and off to bedlam. She was subjected to extreme treatments like solitary confinement and ice baths, cut off from the friends and family who had been a constant part of her life, and exposed to other patients who were similarly disoriented and being similarly abused. It was from these patients that she learned that cutting herself could be a way to relieve the inexpressable inner tension- and to garner special attention from hospital staff. Though the circumstances come across as objectively horrific, she wrote of her time there with a detachment, at times even a fondness. She explicitly connected some of her experiences to ideas she would later incorporate into DBT- her ice bath treatments inspired the popular DBT technique of instructing the patient to hold ice cubes as a way to replicate the cathartic release of cutting without needing to inflict actual bodily harm After leaving the IOL,  her life continued to be a fragmented mix of trying to actualize her intellectual gifts, falling in and out of unbounded relationships with men- especially her therapist and priests, experiences that foreshadow DBT’s unbounded contact between therapists and patients- and looking for a reason to live. She graduated college in 1968 and finished her PhD only a few years later, in 1971, before continuing on to postdoctoral training in suicideology and psychopathology. Even as an established, 10-year professor at the University of Washington, where she began working in 1977, she continued to feel plagued by a sense of having not accepted herself. In 1983, she took a break from her university job to stay at a Soto Buddhist Monastery in California, where she would learn the concepts of mindfulness that would become integral to DBT. In 1987, she began publishing on DBT theory, shifting to focus on empirical validation studies in the 1990s. much of her personal journey had to be made in secret. She did not publicly disclose her long history of psychological disturbance, nor her BPDi diagnosis, until 2011, at a talk she gave at the IOL.  Up until then her trip to the monastery and other deviations from the straight and narrow professional path had had to be framed to supervisors as choices intended to enhance her career rather than desperate bids to locate herself and stave off a breakdown. Even if she suffered internally, her focus was on how she appeared to others- that is, on her behavior. 

As Linehan prepared to disclose her diagnosis before the IOL in 2011, she understandably worried whether she was doing the right thing, including what impact her disclosure might have on public and professional attitudes toward her work. There’s little evidence that Linehan’s coming out as having BPD negatively affected how DBT is regarded and used. She was speaking from the Vantage of someone in her late seventies, as one of the most revered mental health professionals of her generation.

Linehan’s  conscientious research, her willingness to play the game of the status quo in which she worked, brought DBT acclaim and made it synonymous with BPD. So much was this the case that people with BPD would come to be told that they must seek out DBT, that it was the only choice. 

Moving toward the new millennium, people who received the diagnosis of BPD would now unfailingly be referred to Linehan’s program.

Did you know that Jeffrey Dahmer was diagnosed with BPD?  Dahmer said he killed as an act of love. it was a way to possess the person, to keep them from leaving.

 We can’t experience and reflect at the same time.

 Trauma was more than a bad thing that happened, Van der Kolk found: it could be seen in the body and brain- it did something to people physically. To van der Kolk, his objective and subjective views worked in harmony: trauma was the event and its impact.

In my practice, I define trauma as the experience of profound confusion.

Fonagy had been interested in the treatment of borderline conditions since the early 1990s, and beginning in the 2000s he and his colleagues began to draw a line that connected early chaotic environments to BPD by way of a disorganized attachment style. Chaos, abuse, neglect, and invalidation had the potential to disrupt the natural process of development in a child, forcing a recalibration to ensure survival in an unsafe place with unpredictable caregivers.

Throughout the 2000s, Fonagy  and his colleague Anthony Bateman developed a psychotherapy treatment for BPD called mentalization- based therapy (MBT).  Like the attachment theory it comes from, MBT attempts to synthesize psychoanalytic and cognitive perspectives: it acknowledges the unconscious, emotionally driven nature of experience espoused by the former, as well as the latter’s embrace of the role that cognition plays in our understanding of the world. Drawing especially from Klein’s object relational perspective, which sees human beings as inherently multitudinous, MBT therapists are trained to conceptualize people not in terms of a singular personality but as existing in various “ modes”. 

Though there is a common thread between MBT and DBT of focusing on emotional regulation, MBT researchers have taken special pains to advocate for their method over DBT. Proponents point to MBT’s less demanding structure for patients and the reduced need for multiple therapists or the specialized, skills-based training of therapists. Otto Kernberg and several of his psychoanalytic colleagues developed in the 2000s and evaluated via RCT- a “manualized” treatment called transference-focused therapy (TFP), based on ideas dating back to Kernberg’s influential  midcentury work. Both MBT and TFP have shown strong evidence as effective treatments for BPD, and in some areas- such as reducing subjective experience of distress- they appear more effective than DBT and demonstrate longer-lasting benefits. Nevertheless, Fonagy and Kernberg have done little to dethrone DBT as the de facto treatment for BPD- it is proven difficult to beat Linehan  at her own game. In the United States, it can be hard to find MBT practitioners or ways to be trained as one, as Fonagy  and many of the clinicians following his work are based in Britain. TFP trainings tend to be housed within psychoanalytic institutes, which have shrunk dramatically in number over the last half century and are especially hard to find outside of major metropolitan areas. 

Progress in MBT is marked by increasing one’s capacity to reflect- not changing the content of thoughts or feelings, and certainly not  the circumstances of the past, but instead expanding the space one has to look at all these things from multiple angles. 

Herman wrote that recovery from trauma entailed “mourning the old self that the trauma destroyed”  in order to “ develop a new self”.  but we know this is not the case. We always add, never subtract. All the way down to the psychotic core, we can only be ourselves, and the things that happened to us that make us ill also have the potential to serve as sources of empathy and ideas that challenge a toxic status quo. 

No sense, all modern psychotherapies were built on the backs of the borderline. 

Yet still there is a sense of BPD being something other, less a diagnosis than a curse, undesirable and untreatable. It should be a little wonder, then, that some have come to reject the label entirely, while still others have sought to reclaim it, not as a problem but an identity. 

There is another vocabulary at work on Reddit/BPD that is new and organic, for not from the chosen few of DSM committee leaders but the mad egalitarianism of the internet. Someone might write about her “quiet BPD”- a variant not recognized in any psychiatric manual yet frequently cited in podcasts and online articles, denoting someone’s tendencies towards social withdrawal and depression when distressed rather than impulsivity and attention seeking- while another poster explains that he has recently designated a friend or partner as his new “favorite”, shorthand for the person in his life who will now become the focus of all his hopes of safety and fears of abandonment. 

If you enjoyed this book, you can get it here. 

 

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