Our profession is borderline.
Over 50 years ago, in an effort to aid the U.S. Army in creating a census of psychiatric ailments, symptoms that often appeared together were identified, labelled, and written down. And so the Diagnostic and Statistical Manual of Mental Disorders (DSM) was born.
As medicine progressed, and more physical illnesses were documented and understood, it was only natural for the DSM to take similar form. Neuroscience, which even today is still in it’s infancy, bolstered the claim that these observed disorders could be treated as brain-illnesses — neurological deficits that could be cured like a common cold.
The current revision of the DSM (the DSM-IV-TR) contains nearly 300 disorders, and although it pays lip service to the idea that these categories are not as discrete as they sound, the effect on our profession has been to categorize every client with at least one (and typically 2 or more) of these disorders. Spend a day in any mental health clinic lounge, and you will hear at least one clinician declare their frustration at having to deal with “the borderline” or their feelings of helplessness dealing with “the bipolar one.”
And yet Neuroscience (the same discipline that provided ample data to help foster this categorical approach) convincingly demonstrates that the brain simply doesn’t work this way. It is an analog beast, characterized by a dimensionality so complex, it’s not surprising that we find ourselves defining categories in an attempt to simplify it enough to understand it.
Otto Kernberg, one of the rare masters of dimensionality in our field, conceptualizes personality “disorders” on a dimensional level. These disorders, he argues, are not the discrete symptom clusters we often think of them as. Rather, they are locations on a map — a way for clinicians to communicate more quickly. In his model (note that even here we are still talking about a model — an approximation of reality) one axis is our level of borderline organization: the ability to integrate complex and seemingly contradictory ideas together. Most simply, it may be thought of as the ability to comprehend dimensionality and nuance. The other axis is our level of extroversion or introversion: our willingness to share our internal world or keep it to ourselves.
Diagnosis, then, becomes a shorthand to help us quickly navigate this map. “Borderline Personality Disorder” tells us that the person has trouble integrating contradictory feelings, and also tends to be more extroverted. “Schizoid Personality Disorder” tells us that they have a similar difficulty with integration, but are more introverted. It does not in any way suggest that the person has a specific disease, but instead allows us to more easily identify where on the dimensional map the specific client currently resides.
But our profession is borderline. We have largely lost perspective of the bigger picture, and forget that all of these categories serve only to guide us toward a better understanding of the intricate, multidimensional person sitting on the couch before us. It’s easier for us to remain disconnected, and consider their odd nuances and personality as a disease that can be medicated away and fixed, or worse, as a “lifelong persistent” personality disorder that should simply be “managed” until they go away.
The next time you travel overseas from your home in Los Angeles, tell someone you’re from the United States. When they ask if you know their friend in Atlanta, you’ll have a deeper appreciation for how precise your diagnoses really are.