Through The Looking Glass
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Through The Looking Glass

Women And Borderline Personality Disorder

Dana Becker

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Through The Looking Glass

Women And Borderline Personality Disorder

Dana Becker

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About This Book

This book offers a comprehensive exploration of the relationship between gender, the experience of psychological distress that we currently call borderline personality disorder, and the borderline diagnosis as a classification of psychiatric disorder. It offers a new emphasis on elements of female socialization as critical to the understanding of

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Publisher
Routledge
Year
2019
ISBN
9780429975288

1

From Witchcraft to Hysteria to BPD: A Brief History of Female Insanity

The stage conventions of the role have always emphasized the feminine nature of Ophelia’s insanity contrasted with Hamlet’s metaphysical distress.
—Elaine Showalter, The Female Malady

Women and Madness: A Historical View

The complex story of borderline personality disorder cannot be told without reference to the historical association between women and madness. By the nineteenth century, women had become the most frequent consumers of treatment for “nervous complaints” and had entered into a relationship with male physicians that was to have pervasive and enduring implications for the representation—through diagnosis—of women to themselves and to others. In the nineteenth century, as today, women absorbed a view of themselves that was strongly shaped by societal notions of what constitutes madness. The history of the association between women and madness, however, has its origins in the more primitive association made between women and evil.

Witches, Evil, and Madness

For centuries, witches carried the burden of the opprobrium for women’s evil. As early as the sixteenth century, however, a physician, Johann Meyer, had come to view witches as mad rather than evil or possessed (Ussher, 1992). Although many present-day historians share Meyer’s equation of madness and witchery,1 such a perspective, although intuitively appealing, is reductionistic:
One explanation cannot completely explain the myriad reasons for their [the witches’] persecution or their supposed deviancy. The ‘witch’ may have been a healer, a deviant worshipper of Diana, a lonely spinster, a hated rival, a random woman picked by the picker for his own gratification. She may have been evil, or have practised strange sexual rituals. She may have been ‘mad’ or ‘melancholic,’ was possibly depressed, anxious, and unhappy, (p. 61)
The notion of witchcraft as “undiagnosed madness” does not help us understand why communities singled out certain women for extrusion; it merely passes the locus of blame from the persecutors of these women, who are deemed innocent by virtue of their ignorance of the “true” cause of the women’s distress, to the women themselves, whose behavior is seen to have occasioned the “diagnosis” of witchery and, thereby, brought on their own destruction (Ussher, 1992).
There is no doubt that the persecution of witches did provide an important vehicle for expunging the collective fears and uncertainties of the communities in which they lived. However, one need not subscribe to the witch-as-madwoman theory in order to explain the phenomenon of witch-hunting. In some cases, for example, the persecution of witches may have been attempts to expel from the social order women whose skills in various healing arts as well as in midwifery and abortion were threatening to the medical orthodoxy. The fact that a witch/healer was often successful in her ministrations “was seen as corroboration of her guilt, for if she could effect a cure after … male physicians had failed, she must be employing magic” (Ussher, 1992, p. 56).
As the tenets of science superseded those of theology and philosophy, replacing the notion of “evil” with that of “illness” (Ussher, 1992), control of women through allegations of witchcraft came gradually to be replaced by another potent means of social control—psychiatric diagnosis. Whereas in the eighteenth century during the Romantic period, madness had been defined as “loss of reason” and mad individuals, thought to be primitive beasts, were treated accordingly in a bestial fashion—locked up in primitive madhouses, sometimes chained, and otherwise maltreated—in the Victorian era the definition of madness as loss of reason was replaced by the idea that madness was actually “moral insanity,” or deviance from socially sanctioned behavior.2 The raving lunatics of the Romantic period were pushed aside to make room for their more decorous Victorian counterparts by means of a transformation in thinking about madness that made it possible to identify nearly any deviant or disruptive behavior as “morally insane.” In England, this Victorian domestication of insanity coincided with the gradual increase in the proportion of women in asylums, until by the 1890s the predominance of women among the institutionalized was universal. Paradoxically, however, as the numbers of women patients increased, the proportion of caretakers who were women declined.
Foucault (1965) outlines the transformation in the common understanding of so-called nervous complaints, which had once been seen to be
associated with the organic movements of the lower parts of the body … , they were located within a certain ethic of desire; they represented the revenge of a crude body; it had been as the result of an excessive violence that one became ill. From now on one fell ill from too much feeling; one suffered from an excessive solidarity with all the beings around one. One was no longer compelled by one’s secret nature; one was the victim of everything which, on the surface of the world, solicited the body and the soul. (pp. 156–157)
What Foucault does not mention, however, is that to render an excess of feeling as the defining attribute of “nervous complaints” (i.e., madness) is to feminize those same complaints, for it is women who were (and are still) thought to be the more keenly “feeling” of the sexes. There was a steady movement during the nineteenth century from the perception of nervous complaints as bodily illnesses toward the perception of those same complaints as mental disorders: “As long as vapors were convulsions or strange sympathetic communications throughout the body, even when they led to fainting and loss of consciousness, they were not madness. But once the mind becomes blind through the very excess of sensibility—then madness appears” (Foucault, 1965, p. 157). The association between the “excess of sensibility,” madness, and women had been sturdily forged.

The Medicalization of Madness: A Confidence Game

In 1817 John Haslam expressed the view of the medical profession with respect to insanity in women as follows:
In females who become insane the disease is often connected with the peculiarities of their sex. … It ought to be fully understood that the education, character, and established habits of medical men, entitle them to confidence of their patients: the most virtuous women unreservedly communicate to them their feelings and complaints, when they would shudder at imparting their disorders to a male of any other profession; or even to their own husbands. Medical science, associated with decorous manners, has generated this confidence, and rendered the practitioner the friend of the afflicted, and the depository of their secrets. (Haslam, as cited in Skultans, 1975)
In a patriarchal society such as ours where women have not classically been accorded a status equal to that of men, women’s uneasy relationship to psychiatry may be conceptualized in terms of male-female differences along the dimensions of status, power, and sex roles (Piliavin & Unger, 1985). We can trace this relationship to the emerging prepotence of medicine over other healing arts as the favored treatment for ill women at the turn of the century:
It was the combination of upper class and male superiority that gave medicine its essential authority. … Now at last the medical profession had arrived at a method of faith-healing potent enough to compare with women’s traditional healing but one which was decisively masculine. It did not require a nurturant attitude, nor long hours by the patient’s bedside. In fact, with the new style of healing, the less time a doctor spends with the patient, and the fewer questions he permits, the greater his powers would seem to be. (Eherenreich & English, 1978, p. 83)
Neurology had emerged from general medicine and psychiatry as a separate discipline in the period between the 1850s and 1870s, and it was this new discipline that addressed itself to the treatment of disorders of the nervous system—particularly those that seemed to occupy the borderline between normality and madness:
These disorders, neurologists argued, had been ignored or misunderstood. Alienists3 mistook them for types of madness. General physicians regarded them as gross physical diseases, as purely imaginary or as malingering. Only the most scientific diagnosis could establish their existence and lay the basis for sound treatment. By explaining all of them as somatic in origin, neurologists drew them within the medical model of involuntary sickness. (Hale, 1971, p. 49)
Women lost the place they had occupied over the centuries as healers and midwives. The alleged rationality and objectivity of science was used by the experts then, as it is today, “to neutralize criticism and dissent” (Ussher, 1992, p. 66), as medicine claimed for itself the exclusive right to deal with madness by insisting that it was the brain of the mad person and not his or her mind that was afflicted. Madness was bodily disease, and women were, by nature, “weak, dependent and diseased” (p. 92). Adolescence was considered to be a period particularly fraught with peril for women, as adolescent girls were especially susceptible to nervous excitability, it was thought. Women’s sickness was innate and had its origins in the fact of women’s possession of ovaries and uteruses.

Hysteria

“Diseased” women were to become, in increasing numbers, the primary candidates for study and treatment by members of the newly burgeoning group of specialists in “nerve medicine.” These physicians ministered to large numbers of Victorian women who, bound over to idleness by the strictures of an emotionally repressive society, succumbed to a variety of “nervous” diseases. The early equation of female nervous problems with illness, however, carried with it a dilemma for the male physician: If female sickness were innate and had its origins in the fact of possession of ovaries and uteruses, could the physician not be easily made a fool of by his failure to cure the nervous invalids in his care (Eherenreich & English, 1978)? How could he explain the refractory nature of some of these nervous illnesses? The means out of this clinical dilemma were close at hand.
Hysteria, for some twenty-five centuries before it began to be studied systematically, had been looked upon as a mystifying disease (Ellenberger, 1970). In the view of the ancient Greeks, if a woman remained childless too long, the uterus wandered around in the body, causing extreme pain and a multiplicity of diseases. Hysteria (the meaning of the Greek word is “wandering uterus”) was thought by the Greeks to afflict only those women with unsatisfactory sex lives. By the Middle Ages, however, the tables had turned, and what was thought to predispose women to hysteria was “wanton sexuality, precisely the opposite of the enforced sexual abstinence that was the responsible factor of the ancient world” (Chodoff, 1982, p. 547). Beginning in the sixteenth century, some physicians began to locate the cause of hysteria in the brain, and in 1859 Paul Briquet, in his Traité de l’Hysterie, presented the first systematic study of the disease (Ellenberger, 1970). Although Briquet himself did not subscribe to the sexual theory of hysteria, the notion that hysteria derived from sexual frustration was never completely given up either in the public mind or by gynecologists and neurologists. Jean-Martin Charcot, having studied 430 hysterical patients, found a 20:1 ratio of female to male hysterics, and concluded that hysteria was “caused by the effect of violent emotions, protracted sorrows, family conflicts, and frustrated love, upon predisposed and hypersensitive persons” (Charcot, quoted on p. 142).
It was the artifact of hysteria that finally broke “the gynecologists’ monopoly of the female psyche” (Eherenreich & English, 1978, p. 124). American health books and medical manuals published between 1840 and 1900 commonly refer to the vast numbers of middle-class women stricken by illness, and even commentators of the time remarked upon how fashionable illness had become among this group. In the previous century, women had not referred to themselves as weak, delicate, or sick, nor were they defined through illness. Their nineteenth-century sisters, however, did appear to succumb to nervous ailments at an appalling rate. This is not to say that men were not afflicted with similar symptoms, but that, to an extent, diagnosis and treatment of the sexes differed because of the focus upon—and some might say, the obsession with—the female uterus (Wood, 1973). Physicians of more than one school of thought were swayed not only by their view that women were dominated by their sexual organs; they also held “even less carefully scrutinized beliefs about the social and psychological nature of femininity and its role and responsibilities in their society, beliefs which colored their attitude toward the illness of their female patients” (p. 34).
The history of the treatment of hysteria, neurasthenia, and other so-called nervous diseases in the United States is the history of a movement from the practice of somatic medicine by neurologists in the second half of the nineteenth century toward the professionalization of psychiatry and the enthusiastic endorsement of psychoanalysis in the United States beginning in the second decade of the twentieth (Hale, 1971). It is a story in which women played—and still play—a prominent role, and it is a movement that profoundly affects them.

A “Chattering, Canting Age”

The whole generation is womanized, the masculine tone is passing out of the world; it’s a feminine, a nervous, hysterical, chattering, canting age, an age of hollow phrases and false delicacy and exaggerated solicitudes and coddled sensibilities, which, if we dont soon look out, will usher in the reign of mediocrity, of the feeblest and flattest and the most pretentious that has ever been.
—Basil Ransom in Henry James, The Bostonians
Loss of power or will is a characteristic symptom of hysteria in all its Protean forms, and with the perverted sensations and disordered movements there is always some degree of moral perversion. This increases until it swallows up the other symptoms: the patient loses more and more of her energy and self-control, becoming capriciously fanciful about her health, imagining or feigning strange diseases, and keeping up the delusion or the imposture with a pertinacity that might seem incredible, getting more and more impatient of the advice and interference of others, and indifferent to the interests and duties of her position.
—Henry Maudsley, Body and Mind, 1873
Hysteria, as diagnosed in the nineteenth century, embraced such disorders as hypochondriasis, depression, conversion reaction, and ambulatory schizophrenia (Smith-Rosenberg, 1972). Typically, those said to suffer from hysteria manifested symptoms such as trances, convulsive fits, tearing of the hair, choking, and rapid shifts in mood (Sicherman, 1977). Neurasthenia encompassed a large group of symptoms and conditions as well, ranging from depressive, phobic, and obsessive states to moderately psychotic and borderline states, physical illnesses that were not otherwise diagnosable at the time, and a host of psychophysiological symptoms. George M. Beard, the prominent neurologist who coined the term neurasthenia, once listed forty-eight illnesses with which neurasthenia could be confounded (Sicherman, 1977). Hysteria was thought to be more a female and neurasthenia more a male disease, even though the differences between the two afflictions were often less than distinct (Strouse, 1980). Alice James, as we shall soon see, received both these diagnoses and more in her long career as a patient. Beard considered hysteria to be characterized by “acuteness, violence, activity, and severity” (Beard, Nervous Exhaustion, quoted in Sicherman, p. 41) and neurasthenia by languor. Decisions to diagnose one as against the other were profoundly affected by moral considerations, however:
Where neurasthenics seemed deeply concerned about their condition and eager to cooperate, hysterics were accused of evasiveness—la belle indifference—and even intentional deception. Physicians sometimes contrasted the hysteric’s lack of moral sense with the neurasthenic’s refined and unselfish nature. “The sense of moral obligations [in the hysteric] is so generally defective as to render it difficult to determine whether the patient is mad or simply bad.” By contrast, patients suffering from “impaired vitality” were “of good position in society … just the kind of women one likes to meet with—sensible, not over sensitive or emotional, exhibiting a proper amount of illness … and a willingness to perform their share of work quietly and to the best of their ability.” (first quote, S. Weir Mitchell’s Rest in Nervous Disease; second, Beard’s Nervous Exhaustion; third, A. S. Myrtle’s On a Common Form of Impaired Vitality, Sicherman, 1977, p. 41)
Records from Massachusetts General Hospital (1880–1900) show that patients described as stupid, morally weak, or deceitful were more frequently diagnosed hysterical than neurasthenic. (Sicherman, 1977). Neurasthenia was, in fact, the preferred diagnosis “for those men and women whose diffuse symptoms might otherwise have been dismissed as hypochondria or...

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