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From Psychoanalytical Notebooks 4, 2000 : Psychiatry and Psychoanalysis WHY SO MANY ‘BORDERLINES’?
Jean-Claude Maleval The
borderline diagnosis has been used more and more frequently since the
1970s. This is an undisputed fact. There is an increase in the number of
patients who are presenting the four fundamental characteristics of this
syndrome which conform to the specifications laid down by Grinker in
1968 according to statistical evaluations: —
aggressiveness and tendency to anger, —
problems with affective relations, which are anaclitic, dependent or
complementary, but rarely reciprocal, —
problems with identity, —
feelings of depression, not melancholic but more linked with a solitary
life.1 The
divergencies between clinicians does not focus on the recording of the
phenomenon of increase of the syndrome, they begin when it comes to
looking into its reasoning and its interpretation. The most common
explanation proposed puts forward the progress of knowledge about
psychic functioning which allows the isolation of an illness hitherto
ignored. It is a seductive, optimistic argument which smoothes the
progress of science. It is not ours. An immediate observation allows us
to doubt it: as far as the nature of this illness is concerned, its
principle theoreticians are in fundamental disagreement: for Kernberg
borderline is a stable organisation, for Bergeret it is an astructural
state. We will add that Kohut denies the existence of a borderline
organisation but distinguishes, in the same clinical field, on one side
psychoses and borderline cases, on the other side narcissistic
personalities, which develop specific forms of transference.2
To recap, some take the borderline state to be a larval psychosis,
others to be an undifferentiated state, while yet others take it to be
an atypical neurosis. Such divergences on essential points do not very
well support the thesis of the emergence of the borderline state as a
result of the progress of knowledge about psychic functioning In
fact several factors seem to be brought in which favour the abandonment
of the concept. First a schematic history of the term. The term
‘borderline’ appeared in 1884 in an article Alienist
and Neurologist written by M. Hugues. It describes ‘a frontier
state of madness’. The notion did not respond to a true conceptual
need and was consequently forgotten. The subsequent introduction of the
neurosis-psychosis differentiation, produced in its essentials by
Freud’s teaching, constitutes a period of relative silence on the
question of their limits. If there are debates about them they are
rather in relation to the definition of the concept of schizophrenia.
The lack of precision in the Bleulerian3 notion gave rise to
a profusion of nosological innovations on its fringes: schizoid;
schizothymia, schizomania, schizosis, schizoneurosis, benign forms of
schizophrenia, schizosthenia, apsychotic schizophrenia, schizonoia,
larval schizophrenia, etc. The
birth of the modern concept of the borderline is immediately posterior
to the death of Freud. It came from to two American psychoanalysts,
Adolf Stern and Victor Eisenstein, who wanted to discover certain limits
in Freudian psychoanalysis with certain unanalysable patients who were
nevertheless not psychotic. We
will come back to this. Some
years later came the discovery of neuroleptics. In often succeeding in
reducing delusions, hallucinations and disturbances, these new
medications profoundly modified the psychotic symptomatology, so that
the number of patients cared for outside the hospital increased
considerably. The accent placed on the limit was displaced, while the
first authors proceeded from the limits of neuroses encountered in
analytic treatment, the effectiveness of neuroleptics shifted attention
onto a new clinic of patients placed on the frontiers of psychosis. It
was between 1967 and 1971 that many psychoanalysts in the USA and in
France gave more weight to the borderline concept and that of the
narcissistic personality, endeavouring to confer on them a
metapsychological consistency (Kernberg,4 Bergeret,5
Kohut). Their work met a considerable echo; since then research has
multiplied. At
the end of this century, the borderline state remains a diagnosis in
frequent use. If this is
not because of the pertinence of the constructions which support the
concept, how can its lasting success be explained? Three major givens
seem to be able to throw light onto the phenomenon: rapid development of
biological therapies, which smooth defensive constructions, the
considerable restriction of the field of hysteria and the
misunderstanding of un-triggered psychotic structure. Each contributes
in its way, as we will try to show, to making a place for the
borderline. The
principle characteristics of this concept rest on a wide and poorly
defined semiological description, in such a way that nothing really
prevents its demolition. Certain authors consider that it is within the
borderline states that distinctions must be established: thus for Rinker
(1968) the line between neurosis and psychosis must itself be divided
into four sub-types: from those closest to psychosis to those which can
be confined to neurosis. Others discover original forms, for example
considering drug-addiction as ‘a borderline state within the
borderline state’.6 Still others introduce new concepts
into the same clinical field: pure psychosis (Donnet, Green), marginal
psychosis (Pankow), narcissistic personality (Kohut), etc. An
evolution can be clearly seen in the approach to the problem which
shifts the limit: initially very close to neurosis, it is found today to
be situated more and more within the confines of psychosis.
Nevertheless, while this tendency is dominant, widely varying points of
view co-exist. Some hold the borderline to be a pseudo-neurotic form of
schizophrenia, others opt for a form of neurosis with psychotic
mechanisms; not to resolve the issue, one could go with Kohut on the
pivotal point of narcissistic transference. Or again we could prefer the
position of those who challenge all notions of structural exclusion
between neurosis and psychosis in such a way that there exists a dynamic
equilibrium between psychotic processes and neurotic processes, allowing
all patients to be situated along a continuum in the mental processes.
In short, it is not because of its coherence, even in the hearts of
those who insist that the concept is well-founded, that the theory of
borderline states is remarkable. Even an author such as Green, who,
while he does not challenge the notion, has to comment on it: he writes
in 1976, after having consulted the specialist dictionaries, “the
limits are not all situated in the same places by the different writers,
who nevertheless are supposed to be competent in the matter”.7
Some years later, in 1981, one of his colleagues made a similar
observation: “to the extent that the success of the term is
affirmed”, writes Widlöcher, “one has seen its meaning become
imprecise, confused, even contradictory. In fact one could speak of a
plurality of concepts which certainly cover a widely recognised clinical
reality, but while using criteria so different that the definition of
this new category loses its precision to the extent that the clinical
studies, the etiological hypotheses ad the psychopathological theories
multiply themselves. It is therefore necessary to speak of concepts, in
the plural, of borderline states”.8 Since
then, even in the Anglo-Saxon field, clinicians have emerged who
challenge such a vague notion. For example in an article that appeared
in 1978 in The American journal of Psychiatry, Rich proposes that
patients with uncertain diagnoses be called ‘undiagnosed patients’,
rather than making them into borderline subjects for the sake of
convenience. Similarly in
1989 Wurmser refutes the concept of borderline cases because “it is a
catch-all term which covers very varied areas of psychopathology”.9
In 1974 Flournoy thinks that the borderline problems correspond either
to a latent psychosis tangled with modes of neurotic defence, or to a
neurosis bearing some surface psychotic symptoms.10 Laplanche
and Pontalis, in The Language of
Psychoanalysis consider that the term borderline does not possess a
rigorous nosographic meaning. They consider that, depending on the
concepts of different authors, mainly schizophrenics presenting neurotic
symptomatology, but also psychopathic, perverse, and delinquent
personalities and serious neurotic cases are included in this notion. How
could such a blurred concept as that of borderline know the development
that we acknowledge it? Let
us remember that there is a precedent, that of schizophrenia, which
shows that the indeterminateness of a concept is not an obstacle to its
success as far as clinicians are concerned.
Is it a lack of rigour on their part? Or do they consider it
advantageous to use jumbled notions in order not to shut the patient
into a category which is too constraining? The
rise of the borderlines. Let us return to the period in which the
modern concept of borderline originated. A little after the death of the
founder of psychoanalysis a number of analysts, particularly in the
Anglo-Saxon sphere, noticed an increasing number of patients who balked
at adapting to the type of treatment in which the accent placed on the
interpretation of material is diminished in favour of the analysis of
resistances. Seriousness of regression, depth of narcissism, weakness of
the ego, the importance of the schizoid factor, the explanations differ
but the opinions converge in relation to the scarcity of the signs of
psychoanalysis. In any case, until the 50s Freud’s teaching was still
too present to allow any doubt in relation to the hysteric’s ability
to gain from analytic treatment to emerge. Thus the classic Treaty of
Freudian psychology published by Fenichel for the use of students in a
hurry, while to a certain extent it does efface hysteria, it
nevertheless considers “the best therapeutic results” to be obtained
from it.11 Unanalysable subjects were not yet to be found
among hysterics. Things
were soon to change. Various factors contributed of which the principal
ones were the extension of the field of psychosis, the introduction of
the notion of unanalysability, the growth of the concept of borderline,
and the development of chemical therapies. We must emphasise that these
phenomena appeared simultaneously in the 50s. One of their consequences
lies in the fact that they all contributed to re-evaluations of hysteria
— always reducing it. During
this period the spreading of the work of M. Klein and the translation
into English of the major works of Bleuler are influential in a way that
converges with Fairburn’s work on the schizoid factors, producing a
disproportionate extension of the psychotic mechanisms across the
Atlantic. Leaning on these researches, anyone feels able to proceed to a
re-evaluation of the cases presented by Freud and Breuer in 1895 in
their Studies on Hysteria. It is in San Francisco that a respected
representative of Ego-psychology takes it upon herself. Reichard does
not hesitate: Anna O. and Emmy von N. were schizophrenics. She founds
this diagnosis on various criteria which share a common reference to a
vague notion of accentuated seriousness. Comparing them with three of
Freud’s other major cases, she concludes that these two patients came
from more disturbed families, that their symptoms were more numerous,
that the results of their treatment was less good, and above all that
the weakness of their egos produced a decisive differentiation.
Hysteria, according to her, is a neurosis characterised by conversion
symptoms which derive from unresolved Oedipal desires. She finds
persistent sexual conflicts on the phallic or genital level which can
only be compatible with a minimal degree of ego weakness.12
Consistent with the limitations of her approach Reichard even refuses,
against Reich,13 Fairburn and Marmor,14 to
consider that oral fixations could be part of this pathology. Most of
the Ego-psychologists approve of her effort to put hysteria in its
place. Thus when, twenty two years later in New York (1978), Krohn
writes the monograph which codifies the renewed hysteria, he emphasises
that what determines it is founded in the end on the functioning of the
ego. He considers that the debates concerning the degree of libidinal
maturation detectable in this neurosis, which lead one to discern a
genitalisation of the mouth (Reich) while another cites oral use of the
genitals (Marmour), evoke the scholastic debates on the sex of angels.
We can hardly disagree with him. In
any case no one inquired into Freud’s reasons for considering that
hysterics existed who were ‘not very prone to conversion’ producing
problems more psychic than somatic.
Reichard rejects them as a sleight of hand, considering that
notions of ‘hysterical psychosis’ and ‘dementia’
belong only to old psychiatric terminology. To this she prefers
the Bleulerian renovation promoting a tentacular schizophrenia. She
accepts that the diagnosis of schizophrenia remains obscure but does not
doubt that it comes first from a deficiency of the ego. Like Bleuler,
she considers that this pathology is very common and is not necessarily
of a psychotic nature.15 In fact, into this confused mass of
schizophrenias, in which the majority of patients will be found, her
colleagues are already introducing new discriminations beneath which the
great neurosis will succumb even more. The
constriction of hysteria is supposed to isolate a pathology which
constitutes a good indication of analytic treatment and of which the
prognosis is judged to be favourable. Fenichel, Fairburn, Glover,
Reichard all agree on this point. This is less the case by the beginning
of the 60s. At this time Ego-psychology conceives the notion of ‘analysability’.
Shortly afterwards its negative, ‘unanalysability’, will be heard
like a gangrene all the way to the reduced field of hysteria. It is in
New York, precisely where Kris’ study group is elaborating
Ego-psychology that, according to Easser and Lesser, from 1965, the
repeated inability of analytic treatment to reverse the course of
hysterical symptoms, leads therapists to uncertainty, discouragement and
disinterest, even causing some to turn away from this field of
unproductive research.16 From this time only a restricted
number of subjects sufficiently mature and adapted are to be included in
the category of ‘hysterical personality’. They will have to be
differentiated from a large group of ‘hysteroid’ patients who react
in a negative manner to the efforts of the analytic treatment. Three
years later, still in New York, E. Zetzel divides what is left of
hysteria into four groups within which the ‘analysability’ of
subjects will decrease. ‘The good, true hysteric’, as he calls her,
can only be found in the first category, difficulties arising in the
others.17 The incomprehension which has been installed
between the hysterics and the Anglo-Saxon analysts is carried to its
ultimate point in 1974 in an article by M. Khan: it is towards a
theorisation of a fundamental unanalysability of the great neurosis that
this author directs himself. “The internal world of the hysteric”,
he claims, “is a cemetery of refusals.” Her memories are incarnated
in somatic states of a kind that they lend themselves “neither to
psychic elaboration nor to verbalisation”.18 If we follow
this argument through it is nothing less than Freudian conversion that
should be thrown into the dustbins of psychopathology. In short the very
inventors of psychoanalysis seem, three quarters of a century later, to
be fundamentally rancorous and protesting. Do they not in fact have good
reason? Psychoanalytic treatment has become full of traps: those who
escape the tentacles of Kleinian interpretations risk being called upon
to bring about a good therapeutic alliance or to proceed in order
starting with the resistances. Hysterics are too aware of the
impossibility of the sexual relation to accommodate themselves to these
kinds of knowledge that are being force-fed to them. The
unanalysability of those rare subjects who still enter the reduced
field of hysterical neurosis is a thesis which hardly appears in
texts prior to the 60s. The novelty is judged contemporary with the
advances in the psychology of the ego concerning the notions of working
alliance and analysability. These new concepts require as a condition of
a psychoanalysis the presence in the subject of a sphere of autonomous
ego free of conflicts. It is on the basis of this healthy mode of
apprehension of reality that a transference can be analysed which is
understood as inherent to the lived pathology. In fact, even hysterics
with a strong ego assumed able to profit from an analysis, even these,
according to Krohn (1978) balk now at the treatment-type. “The
hysterical personality”, he claims, “tends to evaluate
hypothetical-deductive words and reasoning, even if the person is
intelligent and capable of such reasoning. When she functions in this
way verbal interpretation loses its therapeutic effectiveness. The
hysterical personality hears words as caresses, gifts or chastisements.
She often uses them to try to combat the mistaken explanations of her
behaviour.” One gathers from these lines that the ideal analysand
according to Krohn and Ego psychology is a rational being capable of
distancing herself from all manifestations of her unconscious. On
grounds such as these analytic treatment would not even be adapted to
those who wanted to become analysts, even to the least neurotic among
them. Nothing in common with this irrational, infantile, contrary being
who would be, according to him, the hysteric.
“This kind”, he continues, “judges the interpretation as
being proper to the therapist only as long as he remains a passive
receptor. This disinvestment of words is the integrating part of the
cognitive style of the hysterical personality. The inattention to words
becomes a mode of banal defence for the hysterical personality who often
simply does not hear the therapist. Her wish is to observe him speaking,
to listen to the tone or quality of his voice, while considering the
words as a boring and unimportant part of the therapy. In relation to
some patients such an attitude to words and thoughts can be usefully
interpreted as characteristic resistance. With others this attitude
cannot give way to interpretation, so that the results of the treatment
can be limited. With this last type of patient, interpretations remain
unheard for a long time, earlier insights are forgotten, such that the
masculine and scientific therapist who understands ‘such complex
things’ is responsible, for the author, for all the insights except
the most superficial”.19 At this point we are not surprised
that such patients are often accused of manipulation, sometimes
provoking the therapist into reacting with anger or anxiety. Krohn does
not forget to note that the difficulties encountered in the treatment
can lead to measures of retaliation on the part of the analyst. So the
hysteria of which he speaks to us is a neurosis ‘which slips away’,
according to the title of his book, a neurosis of which the field of
extension shows itself to be considerably amputated in relation to
Freudian hysteria. Does
this not remind us again that the first hysterics treated by Freud,
those with whom he invented psychoanalysis, presented on the contrary
serious forms of neurosis? “To date I have only been able”, he wrote
in 1904, “to establish and try out my therapeutic procedure on very
seriously ill patients, on more or less hopeless cases. I have only had
access to patients who have tried more or less everything else without
success, who have spent years in institutions (…). Psychoanalysis has
been created on a study of patients incapable of adapting themselves to
existence and to their inattention. It is a
great triumph for it to
see a great number of these unhappy people rediscover the possibility of
living”.20 Everything leads us to believe that the New York
progress in psychoanalysis led to a considerable restraining of the
field of action in the analytic treatment at the same time that hysteria
was reduced to shrinking away. Well
before Krohn’s work, a large part of hysteria had been shifted by his
colleagues into other nosological categories. If a delirious idea or
some suspicion of hallucination were discerned, the concept of
schizophrenia was in general called up. In any case, between this and
the remains of hysteria a field was formed, constituted by patients who
fitted badly into the analytic process disinfected by the therapeutic
alliance. To circumscribe it new concepts had to be developed, ‘pure
psychosis’, ‘affective perversion’ or ‘narcissistic
personality’, but it was above all the category of borderline that
acquired wide usage. Freud
ignored it. It was introduced in its modern form in 1938 by Adolf Stern,
an Anglo-Saxon analyst, but it was above all Victor Eisenstein who, from
1949, established the basis of its acceptance.
One after another found their departure not within the scope of
semiological research, armed with statistical work or with a review of
established criteria, rather it was from the difficulties encountered in
the therapeutic treatment with certain patients that the notion of
borderlines arose in their writing. They considered that despite the
apparently neurotic symptomatology presented by certain patients, they
did not behave in the treatment like ordinary neurotics.
Eisenstein observed for example that they tended to transform an
interpretation into a ‘threat’. The
real fortune of the borderline concept seems to have been correlative
with the introduction of unanalysability promoted in the 60s by New York
Ego psychologists. All agreed, following the work of Knight (1953), in
considering that the weakness of the ego in borderlines rendered them
little able to form a ‘therapeutic alliance’ deemed necessary to the
progress of the psychoanalytic treatment type, such that the therapeutic
methods had to be modified with certain patients. In 1974 Green put
forward the opinion that it would perhaps be better to consider them as
‘borderlines of analysability’, adding, “one knows that what
characterises these clinical pictures is the lack of structuration and
organisation — not only in relation to neuroses, but also in relation
to psychoses” — thus joining Bergeret against Kernberg.21 What
is it from then on that differentiates a borderline patient from an
hysteric made acrimonious? Essentially a notion of excess proper to the
former: the weakness of the ego more marked, libidinal regression more
accentuated, richer symptomatology. On this basis of deficiency arise
problems of identity, acting out, hallucinations, and passing delusions.
That it was necessary to integrate great
hysteria into this pathology Kernberg suggested clearly when he
included the dissociative problems of the DSM.
Moreover Krohn places Esser’s ‘hysteroids’ and Abse’s
‘hysteromorphes’ in the same category. The
work of the New York analyst Otto Kernberg constitutes today one of the
major references concerning borderlines. His 1975 work on borderline
personality problems aims at a complete, methodological study of this
nosological entity. He considers that ‘borderline’ describes “an
organisation of the personality which is neither typically neurotic, nor
typically psychotic”. He tries to describe it by writing of the
persistent problems in ego functioning. In the same year in France
Bergeret published La dépression
et les états-limites. The title is justified because he believes,
in opposition to Kernberg, that depression constitutes the most
characteristic symptom: it proves to be an evolutive risk constant in
borderline pathology. Further, in an original way, he considers that
this testifies to an astructuration. The subject
would be too massively dependent on the variations of external
reality to fit the solidity and fixity of one of the two structures that
he recognised: the neurotic and the psychotic. Kernberg and Bergeret
differ on several points in relation to the metapsychological
apprehension of the borderline; nevertheless they agree in considering
that in most cases modification of the analytic treatment type was
necessary in order to deal with such patients. On what was to be
modified there were deep divergences: Bergeret proposed “an
organisation in two stages of the treatment type in what concerns the
interpretative game of the analyst.” It entailed first dealing with
the pre-genital problematic before analysing, at a second stage, the
Oedipal material.22 In reply, Kernberg proposed ‘a
psychoanalytically inspired interpretative psychotherapy” which takes
place face to face, which aims to reinforce the ego, clarify reality and
not allow the transference develop too much.23 The
similarities between ‘rancorous’ hysterics and borderline patients
appears to be interesting. Each one notes that the latter possess a
large number of hysterical traits: their exhibitionism is described,
their narcissism, their erratic behaviour, their intolerance of
frustration combined with a propensity to angry behaviour, the common
presence of conversion phenomena, and the increased frequency of this
pathology in women. In the domain of sexual life the majority of the
authors describe problems with object relations, resulting from the
persistence of Oedipal conflicts, which lead to an unrealistic
idealisation of the partner. It results in an instability in
heterosexual relations bringing out the most banal means utilised by the
hysteric to maintain her desire unsatisfied. On the other side the
borderlines show themselves to be subjects who adapt badly to the
analytic treatment and are changeable and sarcastic, we are told.
They show themselves to be disagreeable with the therapist,
trying to manipulate him. Bion claims that they dodge the comprehension,
avoid insight, paralyse the dynamism of the analytic process; in
apparent agreement, they conceal in fact a rejection of interpetaions.24
The similarities with what Krohn claims concerning the attitude of
hysterics in analysis is clear to see.
All of which leads us to believe that the same causes produce the
same effects. The similar handling of the treatment, centred on
reinforcement of the ego, provokes identical rejections on the part of
patients no doubt less differentiated than their therapists suppose. The
case of Gilberte An
observation of a borderline syndrome, qualified as ‘very pure’ by
Bergeret who reported it, allows us to put this hypothesis to the test.
It concerns Gilberte, a very beautiful young woman of 29, who is
suffering from depression for which she has already consulted several
doctors. Without success.
She has also recently interrupted an attempt at analytic treatment. It
would be difficult to find a more exemplary observation of the most
common form of this neurosis met today in our culture. The need to
maintain desire unsatisfied is manifest. “The frustrations of
childhood”, wrote Bergeret, “had left in her an effective
inexhaustible protest, an irreducible unsatisfaction, a permanent
fishing for favours”.25 Seductive behaviour correlated to a
shrinking away as soon as the other looks as if he is going to respond
to this seduction is noticed by the analyst from the first meeting. We
see that she is interrogating the master, going from doctor to doctor,
lying in wait for faults in their knowledge, ready to expose it, as the
first attempt at a psychoanalysis, quickly ended, suggests.
In her love relations she is looking, as Lacan points out, for
“a master over whom she can reign”, which she finds by taking a
lover much older than herself, with the allure of authority but
seriously wounded in the war. Bergeret commented pertinently: “She had looked for a
relation with an ideal protector and this she found, while at the same
time she could dominate him and keep him at a distance.” Even the
childhood seduction scene was there. What would have been associated
with it remained marked by a partial repression. We know that Freud had
started to build his theory of hysteria on similar material, so
characteristic is it of the hysterical fantasy. Why
then does Bergeret not consider this patient to be an hysteric?
It seems that there are two essential reasons. The first is the
absence of a specific symptomatology, in particular that of conversion,
apparently lacking. In fact, according to him, “every neurotic picture
is more often dominated economically by symptoms rather than by
depression”.26 An affirmation which the banality of the
association of somatic ailments and depressive feelings in the
contemporary hysteric contradicts, even more than the fact that most of
the American authors describe the presence of conversion phenomena in
borderlines. Further, if Gilberte were hysterical she would have been
able without too much difficulty to adapt to the treatment type; however
Bergeret only describes three preliminary sessions without indicating
whether or not they constituted the prelude to analytic work.
Effectively, the experience shows that after a first unsuccessful effort
due, according to Bergeret, to the inexperience of the analyst, too
quick to disengage the Oedipal desires and to handle the penis and the
maternal breasts, it thus proves to be difficult, not only to undertake
a second treatment, but even more to make it good. Everything leads us
to believe that if Gilberte did get involved again she would turn out to
be a difficult patient, ready to argue with interpretations, even to
refuse to lie on the couch, trying to get the analyst out of his chair
but ready to push him back into it if he took the risk, in short she
constituted, according to my understanding, the prototype of an hysteric
become a borderline. A badly handled treatment seems to have left her
disabled, undermining perhaps even the symptomatic constructions,
leaving her prey to a depressive state, and no doubt making her into
what was for some an ‘antianalysand’. Which
seems to indicate that the Gilberte case undoubtedly has a more general
interest. It is the modifications brought to analytic treatment by
certain post-Freudians that aroused an increase in the number of
subjects resistant to analysis, a phenomenon which found a more
acceptable justification in blaming the borderlines, rather than taking
up a revision of the well-foundedness of the novelties introduced into
Freudian treatment. In short, ever less analysis of fantasy, ever more
emphasis on the ego. The analyst being thus led to appeal increasingly
to rational comprehension of a subject summoned to form a therapeutic
alliance, he slides towards a position of mastery. At first the hysteric
might be seduced by this, but very quickly she cannot bear it any more,
she panics and turns to the borderline. It
remains only to re-write history erasing the Freudian discovery: Anna O,
exemplary observation of hysteria according to Breuer and Freud, proves
to be a borderline; Kernberg includes the majority of dissociative
problems in DSM-III in the same category; while others
tend to assimilate the mechanism of conversion to the simulation
of an illness in order to cleanse it of all reference to repression. The
misunderstanding of the un-triggered psychotic structure Nevertheless
the borderline concept does not only get its substance by annexation of
a whole branch of hysteria. It has another major source: un-triggered
psychotic structure is misunderstood by many clinicians for many
reasons, the principle one being that many refuse a
priori the very notion of psychotic structure, while those who do
admit it have hardly studied it. Works on this question remain rare. Let
us remember briefly what presides over its identification. On one side,
the presence of signs that testify to the fact that the elements of
subjective structure are not knotted in a Borromean way. In the
imaginary dimension the problems of identity (interweavings of identity,
illusions of doubles, functioning as if, etc.). In the symbolic
dimension the indications of rupture of the signifying chain (neological
creations, irruption of the letter, deficiency of phallic
signification…); in the dimension of the real, the non-extraction of
the object a, which has numerous consequences (fleeting emergence of
unlimited jouissance, opening
up of push to the woman, deficiency of the fundamental fantasy,
affective effusiveness, sign of the mirror etc.). On the other side the
subject must be capable of putting in place a compensating mechanism,
more or less elaborated, to screen the structural fault, by the
construction of a work, by leaning on a partner or on imaginary
identifications, by the adoption of a determining fantasy etc.,
eventually by having recourse to many of these methods. The
appearance of the ‘as-if personality’ of H. Deutsch is an example in
this respect of misunderstanding of un-triggered psychotic structure.
When she objectified this syndrome in 1934, she underlined, according to
the title of her article, ‘their relation to schizophrenia’.27
She claims that her schizophrenic patients gave her the impression that
the schizophrenic process passes through an ‘as-if’ phase prior to
the construction of ‘the hallucinatory form’. Also it is perfectly
justified to consider that what H. Deutsch presents consists in making
evident one of the clinics met in the antecedents of a triggered
psychosis. Lacan also considered this discovery when he drew attention
to it in 1956. He met the ‘as-if’ as a ‘mechanism of imaginary
compensations’ to which subjects have recourse who “never enter into
the play of signifiers, except by a sort of exterior imitation”.28 Emigrating
to the United States in 1934, welcomed by the Psychoanalytic Society of
Boston, in an intellectual milieu in which the analytic discourse was
increasingly putting the functioning of the ego to the fore, H. Deutsch
had no difficulty in considering that the borderline concept provided a
inviting category for the as-if’ syndrome: did it not seem precisely
to bring a contribution to the problems of the ego?
According to this new perspective, it appeared to be coming from
a certain degree of faultiness in the ego — which, in being
accentuated, could give birth to a clinical psychosis — and not as
resulting from a phenomenon of compensation. Nothing stood in the way of
this contribution to the antecedents of schizophrenia could find
themselves captured in the 60s by a concept which many considered to be
a theoretical advancement: its wide and imprecise semiology allowed the
inclusion of most subjects in whom the defences were not structured on a
neurotic or psychotic model identifiable by the classics. It is
precisely during these years that the discoveries of chemical therapy
would multiply such clinical pictures. The progressive reduction of
delirious and hallucinatory phenomena, the fragmentation of the
evolution of psychotics permitted the
much more frequent observation of a wide variety of symptomatic slidings;
nevertheless, despite the neurotic appearance of certain evolutionary
modes, the subjective structure knew no mutation, at worst it was
disorganised, at best the processes of stabilisation were elaborated. In
addition, the foreclosure of the Name of the Father was not interpreted,
so that H. Deutsche’s patients who had psychotic structures presented
the same characteristics as those of Eisenstein who were placed on the
edge of neurosis. They too showed great difficulties in settling into
the treatment type. The borderline concept veils the fact that the
identity of the phenomena of rejection of the interpretations rests on
reasons which are extremely different. Thus it constitutes an
epistemological obstacle in relation to any study of the differences in
conducting the treatment. *** There
certainly is not room to deny that the ‘border’ symptomatology
constitutes an objective syndrome.
On the other hand it is very doubtful that it constitutes a
trustworthy clinical type. The borderlines category has two major
sources in the psychoanalytic field. On one side, it is a creation of a
treatment-type, a notion rejected as much by Freud as by Lacan, who
insisted that psychoanalysis be rediscovered with each analysand; in
fact if an hysteric balks too much against the therapeutic alliance her
pathology risks being considered as coming from the borderline field.
On the other side of this syndrome, in particular when it comes
to H. Deutsch’s ‘as-if’ personalities, one meets subjects with
psychotic structures, not discerned as such, for lack of a sufficiently
precise grasping of it. In brief, Rich commented correctly in 1978 that
the borderline syndrome constituted a junk room in which undiagnosed
patients could be assembled.29 We would add that this happens
when one economises on a rigorous approach to the structure of neurosis
and that of psychosis. No
doubt the borderline concept, born out of the psychoanalytic discourse,
owes its success to circumstances favourable to its expansion met in the
field of psychiatry ever since its emergence. Its spread, since the 50s
is contemporary with that of psychotropic medicines. In somewhat
reducing the subject’s anxiety they take the edge off the defensive
work and the elaboration of symptomatic constructions. They support the
appearance of a new clinic in which unconscious formations are smoothed
over rather than foregrounded, diffused anxiety and depression becoming
dominant. The pictures, formerly classical, are suffused by chemical
therapy in a jumbled syndrome of which the definition is darkly
negative, neither neurosis nor psychosis — such as they were known. Those
clinicians may come again who draw the same conclusions from these
claims as those of Bally-Salin, who, accompanying the introduction of
neuroleptics, observed that they had “the essential effect of
pacifying the ill, which was the achievement of the disappearance of
positive symptoms”. “We were unable”, he continued, “to bring
the patients something which would be sufficient to allow them to
structure a new mode of existence and a new psychic economy. Thus we had
to force ourselves to find something of the sort. That brought me to
analysis”.30 Translated
by Heather Menzies 1.
R.R Grinker, B. Werble, R.C. Drye,
The Borderline Syndrom, a Behavioral Study of Ego-functions.
Basic Books, New-York, 1968. 2.
H. Kohut, Le soi,
1971, P.U.F., Paris, 1974. 3.
J.-C. Maleval, Smembrare la schizofrenia in Clinica. Milan.
Spirali, 1981, 3, pp. 43-59. 4.
O. Kernberg, Borderline Personality Organisation in Journal of
American Psychoanalytical Association, 1967, 15, pp. 641-685. 5.
J. Bergeret, Les Etats-limites in Revue Francaise de
Psychanalyse, 1968, 32, 5-6, pp. 1001-1004. 6.
A.-J. Charles-Nicolas, J.-C. Archambault, J.-P. Macher, Un état
limite dans l’état limite: la toxicomanie in Actualités
psychiatriques, 1979, No 8, pp. 53-57. 7.
A. Green, Le concept de limite in La folie privée. Psychanalyse
des cas-limites. Gallimard. Paris, 1990, p. 107. 8.
D. Widlöcher, Les concepts d’état limite in Actualités de la
schizophrénie (sous la direction de P. Pichot) P.U.F. 1981, pp. 55-70. 9.
L. Wurmser, Un commentaire divergent concernant la pathologie des
cas-limites in Psychothérapies, 1989, No 2, pp.109-116. 10.
O. Flournoy, Les cas-limites: psychose ou névrose in Nouvelle
Revue de Psychanalyse, 1974, 10. 11.
O. Fenichel, La théorie psychanalytique des névroses, 1945,
P.U.F., Paris, 1953. 12.
S. Reichard, A re-examination of ‘Studies in hysteria’ in
Psychoanalytic Quarterly, 1956, XXV, 2, pp. 155-177. 13.
W. Reich, L’analyse caractérielle, 1946, Payot, Paris, 1971. 14.
J. Marmor, Orality in the Hysterical Personality in J.A.P.A.,
1953, I, pp. 656-671. 15.
E.A. Gaw, S. Reichard, C. Tillman, How common is Schizophrenia?
in Bulletin of the Menninger clinic, 1953, 17, 1, pp. 20-28. 16.
B.R. Easser, S.R. Lesser, Hysterical Personality: a Re-evaluation
in Psychoanalytic Quarterly, 1956, XXXIV, 3, pp. 390-405. 17.
E.R. Zetzel, The so-called Good Hysteric in I.J.P., 1968, 49, pp.
256-260. 18.
M. Khan, La rancune de l’hystérique in Nouvelle revue de
psychanalyse, 1972, 10, pp. 151-158. 19.
A. Krohn, Hysteria: the Elusive Neurosis, International
Universities Press. New-York, 1978, p. 323. 20.
S. Freud, De la psychothérapie, 1904, in La technique
psychanalytique, P.U.F., Paris. 1953, p. 16. 21.
A. Green, L’analyste, la symbolisation et l’absence in La
folie privée, op.cit., p. 73. 22.
J. Bergeret, La dépression et les états-limites, Payot, Paris,
1975, p. 300. 23.
O. Kernberg, Les troubles limites de la personnalité, (1975),
Privat., 1979. 24.
W.R. Bion, Aux sources de l’experience, 1962, P.U.F., Paris,
1979. 25.
J. Bergeret, op.cit., p. 165. 26.
Ibid., p. 188. 27.
H. Deutsch, Divers troubles affectifs et leurs rapports avec la
schizophrénie, 1942, in La psychanalyse des névroses, Payot, Paris,
1963. 28.
J. Lacan, Le seminaire III, Les psychoses, op.cit., p. 218 et
285. 29.
S. Rich, Borderline Diagnosis in American Journal of Psychiatry,
1978, 135, 11, pp. 1399-1401. Entretien
du Dr Bailly-Salin avec M. Reynaud et M. Zafiropoulos, Synapse, 1992,
84. Copyright © Jean-Claude Maleval 2003. This text from the website of the London Society of the NLS, at http://www.londonsociety-nls.org.uk. Permission to use material from this site must be sought from the LS-NLS. All rights reserved. Please include this portion of the text in any printed version of this paper. |
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