Reinventing the Wheel

These posts examine modern psychiatry from a critical point of view. Unfortunately, mainstream psychiatrists usually react badly to any sort of critical analysis of their activities, labelling critics as “anti-psychiatry,” whatever that is. Regardless, criticism is an integral part of any scientific field and psychiatry is no different. As it emerges, there is a lot to be critical about.

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I have a particular dislike of abbreviations and cliches as I think people who talk in abbreviations and cliches are likely to think in abbreviated cliches and are more concerned with how they sound than whether they actually say anything meaningful. However, that’s just one of my (many) gripes so now we can turn to this week’s topic, BPD. Sorry, I mean borderline personality disorder except it’s too long to type. And another gripe: I don’t believe this “thing” exists. I never made that diagnosis and spent a fair bit of time unmaking it. By that, I mean I don’t believe the label nominates a unique and readily identified category of abnormal personality that says anything meaningful about the person. Their distress and dysfunction is real but, in my long but intermittent experience (because I worked solo most of my career), the label says only two things. First, it says: “These people have severe and long-standing problems” and, second, “We don’t like them.” Implicit in the second part is “and we don’t understand them at all and wish they’d bugger off.” Mainstream psychiatry, however, is convinced it’s real so it was with little expectation of enlightenment that I watched an educational lecture from the RANZCP this week on managing suicidal ideas in BPD.

The speaker was a professor from Melbourne who works in something called “Spectrum.” It took me a while to work out that it’s a stand-alone clinic within their public Mental Health Services, not a private deal. Their website announces:

Spectrum is a centre of clinical excellence providing leadership in treatment, consultation, support, training and research related to personality disorder and/or complex trauma.

I can’t stand the expression “centre of clinical excellence,” it’s the very lowest grade of BS. The rest of it is full of the cliches, cartoons and the pictures of radiantly happy people so popular with “management consultants” and other pond life. Their website says very loudly: “These people are getting lots of extra money to play with.” The lecture itself started abruptly, with slides of figures they have collected to illustrate that “Borderline personality disorder (BPD) is a serious mental illness (SMI)” affecting about 1% of the population. This has significance, as we will see. It’s serious because, after very dysfunctional lives, about 10% of people so diagnosed die by suicide, even though most of them have had hospital or psychiatric contact in the previous twelve months. However, a substantial proportion of them also repeatedly injure themselves in various ways, mainly cutting and overdoses, so it’s difficult to know how serious they are. As they consume a huge amount of staff time, it’s important to try to sort those who are seriously suicidal from those who aren’t. Here, the speaker mentioned with relish a quote from a Canadian psychiatrist who suggested these people can only cope with their “psychic pain” by knowing that they can end their lives if they wish: “They feel suicidal in order to survive.”

Moving on, the speaker said: “We’ve been trying for 20 years to understand risk assessment.” After twenty years, what we saw was a box with four compartments, depending on whether the person is doing the same old thing with low chance of doing any damage (e.g. cutting as usual, another small overdose) vs. something new and dangerous, like hanging, carbon monoxide poisoning, etc. Armed with that, staff can decide whether to offer no treatment, out-patient appointment or admission. This didn’t seem a weighty outcome to 20 years or work but it led to talking about management in general and of their program in particular.

First, he was clear they have no specific treatment for this condition, and there are no drugs for personality disorder. Most psychiatric drugs are either no help or make things worse. Second, admission to hospital doesn’t seem to do more than cost a lot of money without changing the course of the person’s life. Instead, they offer a ten-week out-patient program of talking and “general management” which seems helpful as, in about 20 years, only 18 of their 5,000 patients have died by suicide during treatment. Several times, he said there is “no rocket science treatment” at their centre. In particular, it didn’t seem to matter what sort of talking therapy was used.

During the questions, he emphasised that training in psychotherapy is very long and expensive, and formal psychotherapy is also long and expensive, so they need something cheaper that can be used by non-specialists. They have adopted something called “GPM,” which means “good psychiatric management” (this implies that there is also something called “bad psychiatric management” but he didn’t elaborate). He mentioned DBT, CBT, MBT, trauma-focussed, insight-focussed, transference-focussed therapies and a few others, to impart “emotional regulation skills” and tide the unhappy people over their latest incident. In addition, they offer a two day course on “good psychiatric management” to staff and that seems to do about as well as anything else in getting people through their various crises and dramas.

One of the questions asked about relationship between BPD and ASD, i.e. between two conditions that didn’t exist until fairly recently, and which share many of the same symptoms and lifestyles. This allowed him to chatter on about “real” and “pseudo” BPD and ASD and neurodiversity and how they’re setting up a neurodiversity clinic, and then to ADHD and polycystic ovary syndrome and how many of each also show the other diagnoses. It went nowhere. Another questioner asked: “Does BPD burn out with the passage of time?” He said they seem to settle a bit after fifty but it can also develop at this age, i.e. some of them settle and some don’t, which wasn’t very helpful.

The final question was: “Do the staff need supervision themselves?” “Oh yes,” he said keenly (implying the question was set up), “absolutely. BPD evokes strong emotions in clinicians and they need to be aware of this.” As a result, they should be under supervision and keep good notes and regularly report to staff meetings and so on. To lapse into jargon, what he was saying is that dealing with these people provokes what Sigmund Freud called “counter-transference,” a well-known complication of all psychotherapies which is normally studied in the training courses the speaker didn’t think anybody needed.

There is a line, I think from Waiting for Godot, where one character says: “That will help pass the time,” and the other replies: “It will pass anyway.” The lecture was just another waste of time masquerading as educating psychiatrists but it helped pass the time on a rainy Tuesday Afternoon (see end). I’ll tell you what I think. First, the speaker doesn’t have the faintest effing clue what he was talking about, and the term “SMI” (serious mental illness) was a giveaway. It’s code for “biology.” He doesn’t know what the word “personality” means. No clues at all. We know he has no theory of mind but in his neat world, data can replace all that metaphysical stuff. That’s all he’s interested in, counting: given the DSM criteria, how many people in the population meet them? What happens to them, how many had bad childhoods, how many failed at school, how many are employed or go to prison, how many have ADHD/ASD/etc., how many die by suicide, how many self-cutters turn into self-hangers … how many staff can we push through our course, how many papers can we publish (60) and books (4) and conferences (innumerable), and so on. Psychiatry is reduced to collecting data points, giving the illusion of progress by charting human distress without actually doing anything to alter it.

He talks of “psychic pain” but has no comprehension of what it actually means. He talks of staff developing strong emotional reactions to dealing with these people, but the nominated patients only get the BPD label because they’re difficult to deal with and have a nasty habit of asking questions the staff aren’t trained or sufficiently mature or experienced to answer. Mostly, these patients are fairly smart and, more to the point, have quite high verbal facility, so they can easily make staff look stupid. Being untrained in the dark arts of psychotherapy, humiliation at the hands of a smartarse patient makes staff angry but rage is easily concealed in the bureaucratic loopholes of the Mental Health Act. Having dispensed with formal psychotherapy, the professor has also discovered that drugs don’t work on personality disorder, which is hardly news as personality is a set of rules acquired by life experiences. There is no possibility of drugs changing acquired rules, they represent different orders of being (that’s metaphysics again, which he avoids like the plague).

Not satisfied with that epiphany, he announced that hospitals aren’t any help, either. In fact, we have known forever that pushing personality-disordered people into hospital often makes things worse, not least because nobody in the hospital knows what to do with them. As a result of their new-old policy of avoiding admission and drugs, their program has drifted down to the lowest common denominator: put the patients into a ten week outpatient course of “structured clinical management” with “clinicians” (presumably nurses, psychologists etc), including giving them a bit to read on relaxation, how to count to ten before punching, laying off the booze, not getting smashed on meth because boredom, go to bed at a sensible time, regular exercise, assistance with accommodation and dealing with social security, and maybe some tablets if the wheels are really starting to fall off. That’s it. Essentially, it’s a matter of jollying them along until the crisis passes. It’s all very practical, common sense and low key and all that, except I published my version of the same thing way back in 1995 [1], years before this mob started their expensive journey.

He was also pleased to report that group sessions turn out to be helpful, which is revealing. It tells us that in psychiatry’s notoriously short corporate memory, the “discovery” of the benefits of group therapy before and during World War II has now dropped below the event horizon. As a result, when people stumble over it today, they think they’ve found something entirely new and give themselves a pat on the back and trips to conferences to talk about it. No doubt this means we can now look forward to all the old stuff being recycled with new, cybertech names, giving the impression that psychiatrists are racing ahead when, in fact, they’re just running madly in circles, like rats in an exercise wheel. But that’s beside the point.

What counts here is the total lack of any grasp of what the problem actually is, of why these people are as they are, because knowing why they’re in that particular mess is essential for knowing what they need to get out of it. Although the speaker didn’t say it outright, his use of the expression SMI reveals he believes the “mental disorder is brain disorder” trope that is taken as gospel by mainstream psychiatry (even though it’s false [2, Chap. 2]). Flowing from that, he doesn’t understand how the person’s life experiences are relevant. Once, he mentioned sexual abuse in childhood but there was no attempt to relate this to later disturbance with suicidal ideas. Especially during the questions, it became clear that this talk was another case of “The more you listen to experts, the less you know.”

So what is this thing called “borderline personality disorder”? A lecture like this should start with a definition of personality, then move to personality disorder, then focus down on their favourite, borderline personality. He didn’t do any of that because he couldn’t. As far as he is concerned, it’s all biological. It’s helpful to know how its peculiar name came about, because these days, nobody knows what it’s borderline to. Instead, the name has just become a scornful label: “Oh, she’s just so borderline.” For the rest, it was a case of reinventing the wheel: hospitals aren’t much use except short term for emergencies; drugs don't help; none of the expensive long-term psychotherapies seems to add anything specific, so it devolves to the same set of non-specific factors described in about 1961 by Jerome Frank [3]; practical help for people in distress goes a long way; deal with the causes of distress, not the outcome; and if the patient is infuriating, look in the mirror and talk about it in your staff sessions but don’t try to pretend you wouldn’t like to punch him for being so smart. So what’s new?

At the end, the chair of the session praised the speaker extravagantly: “… an insightful presentation, really helpful in conceptualising how to work with risk in BPD.” In fact, it was more a talk for medical students but who’s going to complain? The audience feel good about watching it, they collect their brownie points to prove they’re right up to date, psychiatry rolls along, sure they’ve got all this stuff nailed, and nothing changes. Nothing changes because nobody questions anything. None of the audience said “What about a few definitions?” which would have been revealing because the speaker obviously doesn’t have any.

Everybody could duck the issue by saying: “Well, this was just a talk on how to manage suicidal ideas and impulses in these people,” but that evades the issue. If the sole outcome of their “management program” developed at vast cost over nearly 25 years is simply to jolly people along until they get over the latest drama, then that screams out “We don’t have a clue what we’re doing.” How come? Because if they knew what they were doing, they would direct their attention to the causes and not just hold the boat steady while the waves settle down. They would deal with primary causes, like self-perception, mental set on the world, expectations and rules of life, etc., all the squishy psychological staff that their positivist model of science says is irrelevant. Instead of their little feel-good sessions, they would ask what it is that defines people who get this label, how did it come about and what should be done for it?

In fact, what defines them is constant distress coming from mistrust and self-hatred that started with dreadful experiences in early life and continues in a self-reinforcing cycle: bad expectations produce bad outcomes which lead to worse expectations. But that’s not how modern psychiatrists think. For them, it’s all biology and all we have to do is wait for the geneticists to uncover the errors in the genetic code and the pharmacologists to knock up something to correct it and Bob’s your uncle, another miracle cure rolls off the production line. Well, that’s the story. As this lecture shows, that story is getting pretty threadbare. This group have spent a quarter of a century and who knows how much government money, not to mention patients’ lives, discovering what was known 85 years ago. So is psychiatry making progress, as the chair said? Sure it is, but only as long as you don’t look at the history books.

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If you haven’t seen it, there is an excellent article on drug advertising in MIA this week.

Talking of Tuesday afternoons, watch this Moody Blues video from about 1970 with its clunky old computer-generated graphics. Their music was stellar; it’s amazing how these days, we have AI-generated videos that look completely real but music has gone to shit.

References:

1. McLaren N (1995). Shrinking the Kimberley: Isolated psychiatry in Australia. Australian and New Zealand Journal of Psychiatry ; 29:199-206.

2. McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon.

3. Frank, Jerome (1961). Persuasion and Healing: A comparative study of psychotherapy. Baltimore: Johns Hopkins University Press.

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My critical works are best approached in this order:

The case against mainstream psychiatry:

McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon (this also covers a range of modern philosophers, showing that their work cannot be extended to account for mental disorder).

Development and justification of the biocognitive model:

McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge. At Amazon.

Clinical application of the biocognitive model:

McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

Testing the biocognitive model in an unrelated field:

McLaren N (2023): Narcisso-Fascism: The psychopathology of right wing extremism. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

The whole of this work is copyright but may be copied or retransmitted provided the author is acknowledged.