NLS Minute 18


 
 

- 18 -

The “Borderline” Issue

Alan Rowan

Great Britain

 

The idea that psychosis could be ordinary, lucid, latent or normal and thus more or less compatible with everyday life was not such a strange idea to many early pioneers of psychiatry. For example, Eugene Bleuler spoke of latent schizophrenia as, “the most frequent form” adding “these people hardly ever come for treatment”. However if they do, one may discover Bleuler states, “concealed catatonic or paranoid symptoms” behind what in everyday life may pass as minor oddness, unusual moodiness or some discreet exaggerated behaviour or trait. Moreover he noted how a subject might be well aware that others do not share some of his beliefs and thus engage in what Bleuler termed “double book-keeping” by simply concealing – despite a sense of inner conviction -such thoughts from others, including of course their psychiatrist or therapist.

For reasons that are no doubt complex but certainly entail the need, as Foucault notes, to clearly segregate, socially discipline and treat “madness”, rationality and social capacity were soon seen as incompatible with psychosis, in stark contrast to De Clerambault’s idea that, in some instances at least, the psychotic can be a master of rational deduction. However, if subjective disturbances were in this way to be subject to psychiatric classification it was not possible to do away with forms of suffering that exceeded a neat categorisation of such disturbances into (florid) psychosis and neurosis. Thus the concept of the “borderline” emerged, first with Stern, and then more definitively with Kernberg whereby, thereafter, it became incorporated into psychiatric diagnosis as the “axis two” disorders of personality. Indeed the question of how to understand and treat so-called borderline disorders remains an on-going major theme within contemporary psychiatry (Bateman& Fonagy), even as the diagnosis itself is considered incoherent by many, given the extremely high levels of both internal and external comorbidity for all axis two disorders (Zimmerman & Mattia).

This wider context thus represents one potential way to situate our work programme on ordinary psychosis alongside the fact that for Lacan there exists a “differential clinic” – meaning that the treatment of repression/neurosis and psychosis necessitates a radical difference in approach. Up to this point Lacanian analysts saw the majority of “borderline patients” as having a psychotic structure and thus already had a theory grounded way to approach treatment - in contrast to IPA analysts - like Kernberg or Bateman, who struggled with pragmatic adaptations (e.g. avoid regression, genetic interpretations etc.) to so-called classical modes of interpretation. Today as we focus on this clinic of “discreet signs”, where language treats jouissance, we are thus confronted, as Laurent puts it, with the fact that: “What had been established … as a radical distinction between madness as a result of foreclosure and that which is not affected by foreclosure was now being displaced. Between neurosis and psychosis, which hitherto stood apart like two distinct continents, there emerged a passage of generalisation”. What is foregrounded here is not just that the first paternal metaphor of Lacan is one solution among others in terms of how the subject “knots” the Real, Symbolic and Imaginary but that there is no once and for all adequate solution that would do away with the problems of jouissance in life – with the fact that the “body event” always invariably exceeds its symbolic envelope. It is why today the end of analysis focuses not on some final interpretation but on the subject’s relation to his or her sinthome, on the isolation and reduction of the subject’s “jouissance program” to a question of S1’s.

At the same time, as Miller notes, this “excluded third” of ordinary psychosis is to be placed on the side of psychosis and thus differentiated from the “very definite structure” of neurosis – in Freudian terms the presence of an ego, superego and repressed unconscious. When this structure exists problems of jouissance are handled via this structure and in a way that allows the subject to remain, one could say, a character in their story - if inevitably one that will have its tragic dimension. It means that there is a binary difference between those subjects where object a, as cause of desire, is governed by a fantasy construction which ties jouissance to the Other and where this tie is absent.

In florid psychosis the subject proceeds by way of an often massive delusional work something that in ordinary psychosis is avoided. Typical indications from the so-called “borderline clinic” – paralyzing levels of dread or anxiety, a lack of mutuality, the urgency of impulses, the fear of annihilation with its arousal of aggression towards self or others etc. all suggest difficulties that exceed the category of neurosis. However, it is only via a clinic of “discreet signs” that go beyond phenomenological descriptions that we may feel confident in making a diagnosis. This points to a dimensions of our current work program which has potentially significant contemporary relevance to both psychiatry and the mental health field in general, with, it should be said, interesting links to the (largely forgotten) history of both.

 

 

Bateman, A. & Fonagy, P. (2004). Psychotherapy for Borderline Personality Disorders: mentalization-based treatment. Oxford University Press.

Bleuler, E. (1911). Dementia Praecox or the Group of Schizophrenias. International Universities Press, 1950.

De Clerambault, (1942). Oeuvres Psychiatrique. Universitaires de France.

Foucault, M. (1971). Madness and Civilization. Tavistock Press

Kernberg, O. (1967). Borderline Personality Organisation. Journal of the American Psychoanalytic Association, 15: 641-685.

Laurent, E. (2014). Lost in Cognition: Psychoanalysis and the Cognitive Sciences. Karnac Books, p. 4.

Miller, J-A. (2013). Ordinary Psychosis Revisited. Psychoanalytic Notebooks, Issue 26

Stern, A. (1938). Psychoanalytic investigation and therapy in borderline group of neuroses. Psychoanalytic Quarterly. 7: 467-489

Zimmerman, M.& Mattia, J. J. (1999). Axis 1 diagnostic comorbidity and borderline personality disorder. Comprehensive Psychiatry.40: 245-252