Dancing on the Borderline

Part 3

by Alicia Potter

Kara, 40, sits Indian-style at the kitchen table in her Somerville apartment. Her face is open and girlish, and she immediately apologizes for a slight stutter and bronchial cough, neither of which is particularly noticeable. Outside, the neighborhood kids holler, savoring one of the last carefree dusks before school starts. It is approaching Kara's most dreaded time of day.

"Night's the worst," she confesses. "I start thinking that nobody really likes me and nobody really cares about me. And I start wanting to cut and burn myself."

It has been said that the borderline patient lacks "emotional skin." If so, Kara has coped by toughening herself from the outside in. Her arms are a pinkish terrain of scars, grafts, and hardened tissue; her hands are prematurely gnarled from immersion in saucepans of boiling water. Recently, she took a straight-edge razor to her breasts.

"The anger was gone," Kara recalls of the first time she burned herself, by placing a hot iron to her calf. "There was relief and calm, kind of a pleasant feeling at first. I felt like I deserved it, because I was such a horrible, awful person. I wanted to do it some more."

She runs a finger along the skin graft on her right forearm, courtesy of flesh from her thigh. "But in the back of my head," she adds, "there was also a part of me that thought if I do this, maybe I'll get help."

Eventually, her behavior did land her in the hospital. Kara was relieved; she loves hospitals. The child of an abusive, hard-drinking father and a cold mother who barely left her bedroom, Kara displays a classic borderline tendency: the desire to cling to a savior, a rescuer. For her, it's male authority figures, most often a boss, a doctor, or a therapist.

"I know when I've been in the hospital I'm totally out of control," she says. "I'll kick, yell at people, hit things, refuse to cooperate with them. But it's all because I want attention. I want them to show caring, nurturing toward me even if I'm being difficult."

Difficult. It's a word heard often in discussions of borderline personality disorder. Indeed, BPD sufferers, unable to verbalize their emotional needs, are notoriously hard on therapists. Clinicians often turn patients away, unwilling to cope with the borderline's chronic suicide attempts (10 percent of BPD sufferers die by their own hands), slow improvement, and "manipulative" behaviors. Many therapists accept only one or two into their practices; indeed, a psychiatrist approached for this article declined to be interviewed for fear that potential patients would read it and think that he actually liked to treat borderline cases. "They take their toll," he says. One borderline patient who has been hospitalized nearly 50 times in seven years for suicidal tendencies was once told by a therapist: "You are enough to make a woman pull her hair out."

This attitude toward BPD has created a vicious circle. Not only does it reinforce a borderline patient's worst fear -- rejection -- but it also contributes to an information lag within the psychiatric community. Wary of the borderline patient's bad reputation, many therapists fail to keep abreast of current research and treatment methods. When a BPD sufferer enters treatment, most often for a compulsive behavior such as substance abuse or an eating disorder, these clinicians are not prepared to diagnose the real problem. And without proper treatment, the chances of suicide climb.

One such case that made headlines locally was that of Harvard psychiatrist Margaret Bean-Bayog and her patient Paul Lozano, whom she was treating for BPD. Bean-Bayog surrendered her medical license and forked over a $1 million malpractice settlement when her unconventional, sexually charged regression techniques allegedly pushed Lozano to suicide in 1991. Extreme? Yes. More commonly, therapists misdiagnose BPD as bipolar disorder or depression, or encourage extra sessions to ease a client's neediness -- a decision that only intensifies the cravings for attention.

Some clinicians think BPD has been so stigmatized within the profession that the name, and perhaps even the diagnosis, should be reevaluated. One doctor admits to not telling borderline patients their diagnosis; instead, she stamps them chronically depressed. Her rationale? To protect the client from further vilification and to clinch insurance coverage for the requisite long-term care (currently BPD is not widely covered). Marsha Linehan, a therapist and BPD expert at the University of Washington, suggests renaming the syndrome "emotional disregulation disorder," which more accurately describes the BPD patient's inability to control impulsiveness. Therapists specializing in trauma, on the other hand, recommend absorbing the diagnosis into posttraumatic stress disorder, to acknowledge the unusually high incidence of abuse among sufferers.

But the borderline patients interviewed for this story recall feeling relief upon discovering their pain had a name. "I don't feel so ashamed now," says Kara. "I know there is a reason."

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Alicia Potter is a freelance writer living in Boston.