The Letter, Issue 37, Summer 2006, Pages 56 - 71
A PSYCHOANALYTIC PERSPECTIVE ON BORDERLINE PERSONALITY DISORDER
The diagnosis of borderline personality is one of the few categories within psychiatric classification systems which retains the aura of its psychoanalytic origins. However, even this category is going the way of others; in the past many diagnostic categories hinted at some putative underlying mechanism, but the new trend is for categories which blandly describe symptoms or behaviours (for example, panic disorder, or somatisation disorder). The correct modern title for borderline is 'emotionally unstable personality' which has a more neutral flavour - although there is still a subtype of "borderline type". For the rest of this paper, as a nod to the psychoanalytic origins of the diagnostic category, I will use the term "borderline", not least because - as I hope to show - it is a useful and apposite term.
It is notable that new therapeutic "technologies" for borderline personality disorder always involve some adjustment or "tweaking" of older types of psychotherapies. So for example, we have cognitive-analytic rather than just analytic, dialectical-behavioural rather than just behavioural and so on. Clearly, borderlines defy any attempt at sticking to the use of traditional, perhaps purer, models which have to be adjusted in order to make them work. It is no accident that the borderline personality disorder patient points up the very borders between the different therapeutic modalities, and has almost forced the development of therapy as technology. In my view, this effect is symptomatic of the very structure of the borderline. As we shall see, the triangular relationships between the unconscious, the conscious and behaviour are problematic for the borderline - and perhaps this is why therapies have tried to address the tension between these elements of subjectivity as per CAT, DBT etc.. I will discuss this borderline structure from a psychoanalytic perspective, and by doing so, hope to show how a psychoanalytic understanding can be useful clinically, even if pure psychoanalysis as a practice may not be possible. Crucial to any discussion of the structure of the borderline is a discussion of the structure of the subject in general. In my view, Lacan's thesis in this regard is central, as it is in direct opposition to the structure suggested by the ego psychologists. The ego psychology "world view" traditionally underwrote much of the original descriptions of borderline and therefore much of the writing on treatment of borderlines. By contrast, I will demonstrate how a Lacanian view of the structure of the subject might inform a therapeutic approach to these difficult patients.