Where is the Borderline?

borderline investigations, part 1

This is the first installment in a multi-part series. You can read the introduction/overview here.

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Equinox
Red birthmark
Equal light
Equal dark
North to south
Thoth with pen

—Cass McCombs, “Equinox”

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One of my most irritating yet irrepressible traits is that I love to ask my friends socratic questions. The question at the heart of this installment is one such question. Sometimes I like to use social media to aggregate as many responses to my questions as possible, but this question in particular I knew I had to ask face to face, or people would cheat and use google and I would be able to tell, because basically nobody knows how to think about this question, even if they think they do. There are lots of ways to think about it, and sometimes these ways are as unsatisfactory as they are self-contradicting. Hic sunt dracones. So here’s the question: what or where is the “borderline” in borderline personality disorder?

Answers fell into two large, vague categories. The first is what I’ll call the historically informed category. Very few answers fell into this category. Most people answered based on vibes (as most of us do most of the time). The vibes in this case were basically that since borderline personality disorder is the crazy woman disease, and people who have it have crazy mood swings, probably the border is located between extremes of emotion. If not there, then maybe the border is between sane and insane.

These are good answers, based on vibes. Unfortunately, the vibes are a little off.

In these first few essays I’m going to do my best to get the vibes back on. I’m going to tell you where various scholars say the border is—in other words, I’m going to give you my historically informed answer to the question. You can check out my full bibliography here or in the Zoomed Out tab. Then, in a later installment, once I’ve gotten the vibes back on track, I’ll give you my answer based on vibes.

What, you don’t like how vague I’m being? You don’t like my talk of vibes? Well, I don’t really know what to tell you. I never learned how to write Academese because I dropped out of school, first of all. Second of all, as we’ll see once we dig into the literature, scholars of borderline personality disorder don’t do much better. Spoiler alert: no one has known what they are talking about when they use the word “borderline” to refer to a psychological phenomenon, all the way back to the first man who used it in print all the way back in 1938, and there has been basically no consensus ever since. So as for vagueness, incongruence, imprecision, and straight up baffling semantics: you’ll have to get used to these. Thomas Aronson put it bluntly in the opening lines of his 1985 historical review:

Considerable confusion and disagreement remains in the psychiatric literature over the meaning of the term borderline. Over the last ten years a veritable explosion of books and articles on the subject have espoused overlapping and at times contradictory ideas on entirely different levels of discourse: biological, genetic, pharmacological, objective-descriptive, ego psychology theory, object relations theory, separation-individuation theory, and so on. Together, they seem both bewildering and irreconcilable. Despite DSM III’s efforts to impose conceptual clarity, the situation remains a semantic mess.

To quote Riva Stoudt, though, “we are using the same words, so it feels like a shared language.” When we use the word “borderline”, we don’t hold in mind how obfuscatory that language is. We don’t hold in mind the fact that we don’t agree on what we are talking about.

The man who first used the term in print was named Adolph Stern, and he wrote it like “border line”. This was way back in 1938. Sigmund Freud was still alive; in fact, he had analyzed Stern eighteen years before. Stern was among the first generation of psychoanalysts in the United States, and as such, he was a decorated guy—in his field, anyway; psychoanalysis was still kinda seen as weird, sus, (((and Jewish))) by the general public back then. He christened “the border line” in a piece that began as a lecture and then appeared in print in The Psychoanalytic Quarterly. The article was called “Psychoanalytic Investigation of and Therapy in the Border Line Group of Neuroses”. It is a pretty long and confusing article, but Stern does us a favor by drawing a big red X on the map where he thinks the “border line” is right in the opening lines:

It is well known that a large group of patients fit frankly neither into the psychotic nor into the psychoneurotic group, and that this border line group of patients is extremely difficult to handle effectively by any psychotherapeutic method. (emphasis added)

So, the border line, as it was first delineated in print, is between psychosis and neurosis. Well, actually, Stern says the border line is between that and psychoneurosis, which I realize is probably not a word that’s part of your everyday parlance. That’s because we don’t use the word “psychoneurosis” anymore. The word “neurosis” persists today in psychoanalysis, and “neuroticism” persists in the form of a dimension of personality on the Big Five personality traits. In the former, it refers to anxiety-coded bad feelings as responses to internal conflict. In the latter, it basically means “propensity for feeling bad and stressed”. No one talks about “the neurotics” as a group of patients in their clinical work anymore. When Stern says that there’s a group of patients on the border line between psychosis and psychoneurosis, we understand that he’s saying there’s people who aren’t quite crazy enough to be really crazy, but there’s something clearly very wrong with them. They don’t think they’re Jesus, but they’re worse than a run-of-the-mill nervous wreck. In what ways? Well, the patients in this group, according to Stern, show “a fairly definite clinical picture”. He begins painting that picture for us by enumerating 10 traits that these patients share:

1. Narcissism.

2. Psychic bleeding.

3. Inordinate hypersensitivity.

4. Psychic and body rigidity-'The rigid personality'.

5. Negative therapeutic reactions.

6. What looks like constitutionally rooted feelings of inferiority, deeply imbedded in the personality of the patient.

7. Masochism.

8. What can be described as a state of deep organic insecurity or anxiety.

9. The use of projection mechanisms.

10. Difficulties in reality testing, particularly in personal relationships.

Stern goes on to elaborate each item. Incidentally I wanted to share this list with you because if I had to read the words “psychic bleeding”, so do you. But crucially, I want you to see this list so we can later compare and contrast it with the diagnostic criteria for borderline personality disorder that will eventually show up in the DSM-III 40something years later. It strikes me how value-laden so many of these items are. These patients aren’t just hypersensitive, they’re inordinately so. I want to draw your attention to criterion 5 in particular. I don’t mean to do too many spoilers, but I kinda think Stern could have just written that one and called it a day. After all, that’s basically what the article is about. They’re “extremely difficult to handle by any therapeutic method”, those border lines! And how do you know they’re border lines, Adolph? Why because they’re extremely difficult to handle by any therapeutic method, of course. This tautological understanding of what makes someone borderline, though it will be removed from the Official diagnostic criteria, will persist, and persists today, as we will see. This, I believe, accounts for borderline personality disorder’s status as a “wastebasket diagnosis”, as Aronson and others have put it over the years: if someone isn’t getting better in therapy, it’s probably because they have won’t-get-better-in-therapy disease.

Stern, like I said before, was a psychoanalyst, and as a result his list of traits of the border line group makes use of lots of psychoanalytic language. When Stern uses the word “narcissism” he is using it in the psychoanalytic sense; he doesn’t mean it they way people on TikTok use it today. We’ll look more at that word in particular when we talk about Kernberg later on. Other analytic terms of note include “projection mechanisms” and “reality testing”. We’ll talk more about the former in a later installment of this series, when I do some close reading of Glen Gabbard. “Reality testing” is the stuff we all do to make sure we are in the same reality as everyone else; if your reality testing is faulty, you will think that things that aren’t real are real, or vice versa. That’s what’s at the core of psychosis, one of those things that Stern’s border line abuts. I want to make it super extra clear that borderline is at its core a psychoanalytic concept. Psychoanalysis is a discipline that’s based on vibes. It’s a systematized esoteric practice. It’s empiricized dream magick, among other things. I think people who like the idea of “mental health” who don’t know a lot about the history of psychology have a vague sense that mental disorders are not only analogous to physical diseases, but that they are in the same ontological category as physical diseases. I don’t think this way. Even many the people in mindwork¹ land who are most aligned with medicine don’t think this way. You can’t do a blood test for narcissism, you can’t do a PET scan for schizophrenia, you can’t do a breast exam for a personality disorder. You can’t lance psychic distress like a boil and watch the pus run out. The psyche is not part of the body. Affect is not like lymph, nor libido like semen.

But there are mindworkers who think about mental disorders as in some way biologically based. In fact, it’s very trendy in mindwork right now to invoke neuroscience² to explain what’s going on in people’s thoughts, feelings, bodies, and behaviors, the average therapist’s scientific illiteracy notwithstanding. The unstable ground of pop neuroscience is beyond the scope of this essay, though. There are [a comparatively small number of] mindworkers who actually do have medical training and are therefore more likely and more educationally equipped to think about the psyche using medical concepts, as I alluded to above. These are psychiatrists.

There have long been tensions and irreconcilable differences of understanding between psychiatrists and psychoanalysts. Psychiatry and psychology (psychoanalysis being but one subdiscipline) are two distinct cultural projects with two different teleologies, and looking closely at those teleologies is way beyond the scope of this essay as well, but I want you to bear this in mind as you read. The ongoing tensions between psychiatry and psychology bear heavily on the history of the borderline construct. Even at the time Stern was first saying the phrase “border line” in public, and even decades antedating his coinage, psychiatrists were cooking up their own understanding of their own set of untreatable patients who existed in some kind of clinical twilight zone. I’ll take you through some of that history to the best of my ability in the next installment of this essay. I’ll show you where those people think the border is.

While you wait for that (who knows how long it will be—I’ve got quite a few old German words to digest), I hope you’ll try on the idea that whatever mindwork concepts you are attached to in your own life might be just as epistemologically precarious as borderline. I’m not saying you have to reject what you know about yourself or others around you. What I admonish you to do is get used to the idea of holding terms loosely. That will help you pick up what I’m putting down.

1. I don’t like to use the phrase “mental health”. (More on that some other time.) I use the term “mindwork” to refer to what others might call “mental health practitioners” or “mental healthcare” as a catch all for psychotherapy, behavioral therapies, psychopharmacology, etc., because I think it is appropriately vague and vibes-based to encompass such disparate practices as psychopharmacology and sensorimotor psychotherapy and brainspotting, to name a few. “Mental health” and “mental illness” as concepts are likely not ones that you will hear me invoke. I might use phrases like “psychic distress” or “pain” instead.

2. Do not ever speak to me about the Vagus nerve or mirror neurons. “Nervous system”, you’re on thin fucking ice.