Last fall, at the beginning of a large online, undergraduate course in abnormal psychology, I was warned that after reading the textbook I should not attempt to diagnose mental disorders in friends, family, myself, or anyone else.
I immediately thought about a friend who had recently lamented to me that a dating relationship of hers had ended because she had discovered that the man was narcissistic, and maybe mildly autistic, too. She was not as certain on the latter part, because, she assured me, it might take more medical assessment to know that. I was transfixed by her use of the word “more.” Was her perusal and interpretation of MedWeb articles, I wondered, sufficient medical assessment for a diagnosis of narcissistic personality disorder? I realize now that as I stared at her with wide eyes I was beginning to formulate a question—reaching well beyond the personal opinion I surely also had of her at the time—a question that already had a deep yearning in me: I wanted to know what institutional and cultural trends in personality theory had led us as a society to treat the self so casually that a supposedly significantly disruptive pattern in personality function could be correctly perceived, labeled, and pathologized as readily as a common cold.
Let me pause a moment.
What exactly is “wrong” with his/my personality anyway?
And take a breath. A deep breath.
My great discomfort in moments like this one with my friend in which I am told in all seriousness--and much clearly stated fear and pity—that so-and-so has blank personality disorder or is mentally unstable, psychotic, or completely nuts, is symptomatic of a personal trigger--MY trigger. I hate the idea of being “that crazy girl” so much that one of the first things I often tell people about myself when we get close is that I might be the sanest person they’ve met—and then I do my damnedest to prove it. Internalized sexism much? In that trigger is also a projection and a judgment. Parts of me actually want to both distance myself from and better understand people who toss terms like narcissist and borderline into friendly conversation, because some part of me also thinks there’s something important in understanding how and why we aren’t better at talking about personality. I might call this something like “personality THEORY disorder.”
Personality theory disorder is something we’re all going through, as a society, on our own and together. It’s the natural outcome of being violently assaulted by large-scale social and economic forces that don’t care for the people being most affected. Because of this assault, we’re desperate for a theory of mental illness that helps people, but that same desperation is disorienting and distracting us from understanding how to help well. We want to put people first, but we keep putting applications first, thinking that we have to, that we don’t have the means to actually put people first. But we think that we don’t have the means, because we’ve internalized powerful messages that say caring about whole, integrated people requires limitless resources and there just isn’t enough time, love, money, food, counseling, you name it available for everyone. This is just a simple acknowledgment of a history—our history—of plunder and brutality, a history with long arms that keeps sending these messages out, actively and passively. Generations of trauma and disenfranchisement contribute to the ongoing stealing of power from our best intentions to help ourselves, let alone each other. You can see the great loss in this personal and interpersonal ransacking of hope in the huge fights among scientists, researchers, and theorists about impossible problems—an academic stance of powerlessness and a truly disordered approach to personality.
But we can change that; we can put people first again.
At the time of my friend’s lament, it seemed clear to me that she might have an easier time grappling with a failed love connection if there was a sure reason outside herself that the other person was simply too “damaged” or “dysfunctional” to be in a good relationship. There may actually be some utility to this line of thinking. Framing the other person as clinically maladaptive provides an escape from owning our own vulnerability or working on own shortcomings first—and that may be a necessary defense for her. Moreover, calling this sort of escapism out in others, as well as in myself, has certainly contributed to the work I’ve done in community and on myself over the past half decade to create access points to more personal power, and to more skillfully sharing power.
But what do clinicians do on the ground to accurately and compassionately understand, evaluate, and treat for better mental health outcomes in a way that puts the person first?
To be sure, as I work with more people in clinical settings on their relationships, on love and intimacy, on connection and partnership, and on community and cooperation, I will need a more coordinated, strategic approach, based in science and ethics, in order to answer that question, as well as to be with people, non-reactively, seeing clearly the context of popular beliefs about mental illness that may arise, uniquely, in each client’s narratives and dynamics as well. I will likely also need to keep revisiting my own judgments and gaps in understanding as to how and why lay diagnoses occur in the ways they do, including understanding the larger historical context of how personality has been understood, codified, and policed in our country as ill versus healthy. In other words, I will need to confront my own personality theory disordering, and I will need to pay attention to opportunities for healing and liberation.
And you may ask yourself, well, how did I get here?
In 1980, at the same time that David Byrne asked the world to consider the existential nature of standard American success, Reagan defeated Carter, Lennon was shot dead in New York City, and a Norwegian polio survivor gave birth to a girl in Chapel Hill, North Carolina, and named her Anna. Fifteen years later, threading her career through the independent living movement across the American South, my mother hired me one summer to enter data for her from a massive well-being survey into a database at the Missouri Institute on Mental Health. Has car, has food, feels happy, feels sad—I ticked off a long list of self-reported indicators that seemed both profound and meaningless on the computer screen, and I wondered how in the world this information could be used. How could this litany of survey questions make up the whole picture of a person’s well-being?
From my vantage today, this memory is not surprising. From 1980 to 1995—my whole life at that point—not much had changed in the official method of the American Psychiatric Association for assessing mental health. But before 1980 things looked much different.
For more than sixty years, the Diagnostic and Statistical Manual of Mental Health (DSM) has been a main site of power in articulating and enacting theories of “personality illness” across our institutions and woven through our culture in the United States. How the DSM defines disordered and medically significant personality deviation is still being heatedly argued about today and provides an important anchor for understanding how personality has become typed and treated as ill, even beyond the overtly therapeutic setting. The history of the DSM is also an incredible storyteller and reflection of the narrative of our shared personality theory disordering.
The first (1952) and second (1968) editions of the DSM, “reflected Sigmund Freud’s idea of psychodynamics: that mental illness is the product of conflict between internal drives” (Adam, 2013). According to Mayes and Horwitz, “these manuals conceived of symptoms as reflections of broad underlying dynamic conditions or as reactions to difficult life problems” (2005). But in the 1970s, for much good reason, Freud was being heavily criticized and challenged by multiple other schools of thought in psychology, including the humanists, the cognitive behaviorists, and even the human potential movement. With scathing critique form the new feminists and Freudian classical psychoanalysis in the doghouse (Robinson, 1993), the third (1980) and fourth (1994) editions of the DSM flipped the “dynamic” approach on its head, opting for a theory of discrete, categorical buckets designed to meet a supposed need for easily diagnosable, uniquely treatable, and statistically viable mental ills. The DSM-III’s categorical approach, which was billed as a clear and straightforward classification system, handily “imported another role model from central Europe: psychiatrist Emil Kraepelin” (Adam, 2013). Kraepelin was famous for saying that conditions had “unique sets of symptoms and presumably unique causes” (Adam, 2013). With Kraepelin, asserts Nature writer David Adam, the DSM-III erected “solid walls between conditions,” listing out symptoms, which writers like Ronald Levy coached a generation of clinicians to interpret and apply (2013; Levy, 1982).
“In a very short period of time,” write Mayes and Horwitz, “mental illnesses were transformed from broad, etiologically defined entities that were continuous with normality to symptom-based, categorical diseases” (emphasis added) (2005). Concurrently, “a descriptive approach” to the language was purposefully applied to provide “a medical nomenclature for clinicians and researchers” (psychiatry.org), making it easier for clinicians to diagnose and prescribe treatments, as well as for statisticians to collect data on diagnoses. Unfortunately, this shift toward increased diagnosis was “neither a product of growing scientific knowledge nor of increasing medicalization” (2005)—though it certainly led to increased medicalization.
It wasn’t just pressure to reject Freud either. Larger social and economic forces leading up to the 1980s contributed to this rapid and sweeping change in how personality theory and mental illness were forced into a new standardization. According to Mayes and Horwitz (2005),
"This standardization was the product of many factors, including: (1) professional politics within the mental health community, (2) increased government involvement in mental health research and policymaking, (3) mounting pressure on psychiatrists from health insurers to demonstrate the effectiveness of their practices, and (4) the necessity of pharmaceutical companies to market their products to treat specific diseases."
Certainly public scandals like the Rosenhan experiment, published in 1975, in which “patients” who claimed to have a mental illness but did not were successfully admitted to an institution and kept there against their will contributed some pressure to the field of psychiatry to avoid improper diagnoses (Rosenhan, 1975). But shifting views of the legitimacy of psychiatry in the United States were more likely fundamentally affected by human rights challenges to mental “health” institutions that forcibly indentured populations, kept sick and healthy people locked up in unsanitary living conditions, and committed multiple forms of torture, some under the dubious banner of “science” (Deegan, 2011; Souder v. Brennan; ACLU, 2010). At the same time, as government and communities scrambled to treat people in the face of large-scale desinstitutionalization, the 1970s saw a surge in the influence of the health insurance industry, privatized care, and big pharma all of whom—watching their bottom lines—were making it increasingly important to neatly label and put patients into exact boxes or categories of mental health in order to medicalize and monetize the fields of psychiatry and clinical psychology (Lyons, 1984). By the time the Regan administration pulled the plug on funding state mental health care, clinicians had to follow along in order to get patients any kind of treatment at all (Torrey, 2013). By 1994, the DSM-IV “simply added and subtracted a few categories” to this picture.
The 1980s and 90s were terrible years for people with acute mental health problems. But it was also the proving ground for a new movement—bringing the DSM back from the grips of the categorical approach.
Fired up, ready to go!
The categorical approach clearly had some big problems. As David Adam writes, “even as walls between conditions were being cemented in the profession’s manual, they were breaking down in the clinic” (2013). People found that they needed a better way to understand how multiple diagnoses or intersecting diagnoses should be treated. Adam also notes that a persistent problem has been that “biologists have been unable to find any genetic or neuroscientific evidence to support the breakdown of complex mental disorders into separate categories” (2013). Professionals in the field were coming to understand with greater clarity that a different answer, a new proposal, was needed. The establishment considered what the reform movement came up with—a “dimensional” approach—to be dangerously radical.
But as gender studies, race studies, disability studies programs, and other interdisciplinary focuses flourished across institutions of higher learning, the idea of a spectrum of identity became increasingly popular in academic settings. And the idea that mental health might also exist on a spectrum, along with new science about the brain and human biology, became an exciting new area of research. This new approach to the DSM, combining a goal of accurate diagnosis with a throwback to the Freudian view of “dynamic” personality, was lauded for its unique inclusion of 21st-century research technologies, as well as leaving open questions that remain about what is know-able about a “spectrum of personality” (Adam, 2013).
Enter the DSM-5.
In 2009, Obama supporters were fired up and ready for the president to go to work on real progressive change—with great hope comes great reality checks? The Great Recession was in full swing and I had just moved to the Bay Area from Louisiana. And in 2009, Lisa Cosgrove, Ph.D., and Harold J. Bursztajn, M.D., noted that,
"the fact that 70% of the [DSM-5] task force members have reported direct industry ties—an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties—shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed."
Since the DSM-5 was published in 2013 it has received sweeping criticisms. Some say that it is not much different than the DSM-IV, that it didn’t do enough to change the categorical approach. But others, like Allen Frances who led the development of the DSM-IV felt dubious to say the least about the ambitions of the DSM-5, attacking the new edition in a Mother Jones interview as liable to cause new epidemics of over-diagnosing and over-prescribing (Mechanic, 2013). Today, the National Institute on Mental Health (NIMH) is apparently so discouraged with the whole DSM system that they have replaced it with something called Research Domain Criteria, an initiative aimed at being a biologically-valid framework for understanding mental illness:
RDoC research starts with basic mechanisms and studies dysfunctions in these systems as a way to understand homogeneous symptom sets that cut across multiple disorders, rather than starting with clinical symptoms and working backwards. (National Institute of Mental Health)
The NIMH has not given up on the dimensional approach, but it is clear that they believe more research is needed.
But maybe we’re still missing something big in the DSM-5 debacle, maybe “madness” doesn’t exist on a single-person spectrum either. As the Association of Humanistic Psychology asserts, it may be that “nourishing environments can make an important contribution to the development of healthy personalities” (2014). It may be that a nourishing clinical setting can make a contribution to how we grapple with our own and each other’s mental health and well-being. If that’s true, maybe what we need, along with brain science, advances in biological knowledge, and money pouring through pharma, insurance companies, and privatized care, is to develop a whole-person, whole-society spectrum approach to mental health, and to teach it widely to clinicians, as well as beyond the formal clinical setting. If we are paying attention, we might notice that there is a movement in our country right now that is already putting people first.
Complicate the narrative.
No matter the causes of the adoption of the categorical approach in the 1980s, it was misguided and inadequate, and it wreaked havoc on our ability as a people to care for each other. But a dimensional approach to diagnosing personality disorder, if it remains in the hands of “scientists,” may not do any better at helping our society treat people clinically, or at helping us treat each other better interpersonally—and that is a gamble we can’t make.
In 2015, this too remains true: “no one has yet agreed on how best to define and diagnose mental illnesses” (Adam, 2013). But it seems clear and vital that we need to stop putting people in boxes—literally, our country needs to stop using prisons to throw people with mental illness away, and as a society we need to stop using any number of institutions to foster madness, both in a physiological and an emotional sense. We also need to think hard and take action so that we don’t let people succumb to “the hands of the drug companies” (Mechanic, 2014) or structural racism and other forms of oppression.
When Freud says that “we are confronted with the conclusion that there is indeed something congenital at the basis of perversions, but it is something which is congenital in all persons, which as a predisposition may fluctuate in intensity and is brought into prominence by influences of life” (1920, p.34), I hear in his insight an understanding of how we might pervert theory itself in our influence-able development as a relatively young society. We can ask specifically how we are raising our young people—what kind of nurturing do they receive? In 2015, young people still face industrialized schooling, a military industrial complex, a prison industrial complex, poverty, racism, gender oppression, and more—these are all things that no doubt contribute to a disordering of personality at a young age. But they are also things that might disorder a theory of personality, making it not that surprising that the DSM has been such a hot mess for so long. One might even joke that the DSM, with Freud in mind, has some daddy issues—and tragically not be so far off.
In Jung (1970) we find the seeds not just of the individual dynamic personality, but of the spectrum of collective experience:
"The dynamism of instinct is lodged as it were in the infra-red part of the spectrum, whereas the instinctual image lies in the ultra-violet part. . . . The realization and assimilation of instinct never take place at the red end, i.e., by absorption into the instinctual sphere, but only through integration of the image which signifies and at the same time evokes the instinct, although in a form quite different from the one we meet on the biological level."
What is the collective will of our society today? What are we creating? And what do we need to heal, together? Putting people in boxes and categories, making judgments based on some essential characteristic, using each other, making profit off the backs of some, slavery, hierarchy—these are all deep societal wounds that we are still waking up from. The categorical approach to the DSM may have been one cycle of unfolding consciousness in response to these woundings—but it was also a product of that same trauma. You can see this in its aim to regulate human experience and human bodies as much as it attempted and failed to regulate the actual care of humans by responding to human rights violations or by growing compassion, empathy, and equity in our society. The DSM-5, perhaps another botched attempt to change this, is another sign that personality theory and systems for understanding mental health in our country yearn for and need a lot of healing right now—healing and liberation.
Intersectionality, a word that hasn’t made it into the dictionaries yet, is a feminist concept that sees the study of intersecting identities as critical to social well-being. Intersectionality assumes that selves exist on a spectrum, that our various identities are dynamic and multi-storied. But it also tasks us with grappling with additional vectors—including each other, how we are viewed and affected by our social rank and our cultural backgrounds. In other words, maybe dimensionality doesn’t exist along a single spectrum—maybe the dimensionality of mental health is already a spectrum, one that includes race, gender, ability, etc. Every time you assess a person or a mental health concern on a spectrum, the act of connecting those dots already creates another spectrum of meaning. Another way to say this is that my being Jewish and a woman is uniquely meaningful to my sense of self and to my mental health. My “womanhood” exists on a spectrum and my “Jewishness” exists on a spectrum, and at the same time my social identities exist on yet another uber spectrum. And me being a Jewish woman married to a black man further complicates my narrative. And that’s exactly as it should be.
In 2014 when a white officer, David Ried, shot and killed Aura Rain Rosser, the media, in a too-familiar shock, took a breath to acknowledge “the deadly intersection of mental illness, race, class, and gender” (McCoy, 2015). But in January of 2013 when Ried was let off without any charges, #BlackLivesMatter did not shy away from the case or from making it a central party of their ongoing rallying cry (Adamopoulos, 2015). They did not say, no, we cannot stand up for this life—it is too insane, too black, too poor, and too female to matter. Instead, they took to the streets, only adding fuel to their cause.
The power of the #BlackLivesMatter movement is palpable, and that’s because they’re doing one thing absolutely right—they’re putting people first. With every protest step, they’re saying that what matters right now is the preciousness of life, and in the common refrain, “we’re sick and tired of being sick and tired” (and dying) because we’re black, they are literally saying life is what matters. And they’re saying, as one recent Twitter post that was retweeted over a thousands times states, “3 black women started #BlackLivesMatter. 1 is Nigerian-American, 2 are queer. Complicate the narrative… Because all #BlackLivesMatter.”
As a clinician I will always have access to many tools: the DSM—all five versions, a sea of other publications and research in psychology and psychiatry, new technologies and new scientific discoveries, experts and veterans in the field, and even the insights and shortcomings of our global parents in the healing arts. I also have all of human experience, including art and social change activism, to bring to bear on my whole self as I work to have a healthy and empowered theory of personality. And I absolutely need all of me to do this work.
When my friend told me that her ex was narcissistic, I did not shut her down. I did not pathologize her experience by prescribing her a course of therapy that I wasn’t sure she needed, and I did not shame her for being exactly where she was in that moment in her own theory of personality. I took all of me and I gave it to her in that moment by getting really curious, listening to her, loving her, and making damn sure that I never lost track of her as a person first.
ACLU. (1 September 2010). “ACLU history: Mental institutions.” Retrieved from https://www.aclu.org/aclu-history-mental-institutions
Acton, G. S. (1998). “Classification of psychopathology: The nature of language.” The Journal of Mind and Behavior, 19: 243–256. Retrieved from http://www.personalityresearch.org/acton/language.html
Adam, D. (24 April 2013). “Mental Health: On the spectrum.” Nature. Retrieved from http://www.nature.com/news/mental-health-on-the-spectrum-1.12842
Adamopoulos, A. (31 January 2015). “Protesters march in Ann Arbor after prosecutor declines to press charges against officer.” The Michigan Daily. Retrieved from http://www.michigandaily.com/news/protesters-march-following-aura-rosser-decision
Association of Humanistic Psychology. (2014). “Humanistic Views & Methods.” http://www.ahpweb.org/about/what-is-humanistic-psychology/item/33-humanistic-view--methods.html
Cosgrove, L., Ph.D., & Regier, D. A., M.D., M.P.H. (1 January 2009). “Toward credible conflict of interest policies in clinical psychiatry.” Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/articles/toward-credible-conflict-interest-policies-clinical-psychiatry
Deegan, P. (30 August 2011). “Lead Shoes and Institutional Peonage.” Retrieved from https://www.patdeegan.com/blog/posts/lead-shoes-and-institutional-peonage
Ebert, A., & Bär, K-J. (2010). “Emil Kraepelin: A pioneer of scientific understanding of psychiatry and psychopharmacology.” Indian Journal of Psychiatry, 52(2): 191–192. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2927892/
Freud, S. (1920). “The sexual aberrations.” Three contributions to the theory of sex. Nervous and Mental Disease Publishing Co.: New York.
Jung, C. G. (1970). “On the nature of the psyche.” Retrieved from http://frithluton.com/articles/what-is-an-archetype/
Lyons, R. D. (30 October 1984). “How release of mental patients began.” The New York Times. Retrieved from http://www.nytimes.com/1984/10/30/science/how-release-of-mental-patients-began.html?pagewanted=1
McCoy, A. C. (2015). “Police brutality, mental illness, and race in the age of mass incarceration.” Nursing Clio. Retrieved from http://nursingclio.org/2015/06/30/police-brutality-mental-illness-and-race-in-the-age-of-mass-incarceration/
Mechanic, M. (14 May 2013). “Psychiatry’s New Diagnostic Manual: ‘Don’t by it. Don’t use it. Don’t teach it.’” MotherJones. Retrieved from http://www.motherjones.com/politics/2013/05/psychiatry-allen-frances-saving-normal-dsm-5-controversy
Robinson, P. (1993). Freud and his critics. University of California Press: Berkeley, CA.
Rosenhan, D. L. (1975). On being sane in insane places. Retrieved from http://www.bonkersinstitute.org/rosenhan.html
Souder v. Brennan. (1973). Retrieved from http://www.leagle.com/decision/19731175367FSupp808_11075.xml/SOUDER%20v.%20BRENNAN
Torrey, E. F., Ph.D. (29 September 2013). “Ronald Regan’s shameful legacy: Violence, the homeless, mental illness.” Salon. Retrieved from http://www.salon.com/2013/09/29/ronald_reagans_shameful_legacy_violence_the_homeless_mental_illness/
Fatalistic Attraction: Re-thinking Hollywood’s Influence on Borderline Pedagogy (essays from graduate school)
Fatal Attraction has been recognized as THE silver screen portrayal of borderline personality disorder (BPD). As one Psychology Today blogger notes about the movie, “Viewers watched Alex Forrest and began to link the behavior and inner life of this troubled figure with BPD in a process that continues to cement in the mainstream mindset to this day” (Clyman, 2012). The film’s impact on popular beliefs about BPD now extends beyond regular entertainment consumption and into clinical psychology practice, both indirectly through clinicians’ background cultural knowledge and directly by gaining acceptance and applause as a useful tool for teaching about BPD in the field. It is this pedagogical use of the film that this essay attempts to take a critical look at, considering the risks involved in using a Hollywood dramatization to teach about BPD.
This essay begins what should be a much larger discussion on cinema pedagogy in clinical disciplines, outlining preliminary interpretations only and taking a brief, but closer look at our culturally-situated viewer biases especially toward sex/gender. The conclusion of the author is that using Fatal Attraction to teach clinicians about BPD may be highly problematic. In what seems to be a dramatically (pun intended) fatalistic lesson on BPD—mad women are bad women—what is being sold to a generation of developing clinicians is a missed opportunity to widen our empathy for BPD clients, the very thing we need to do in order to recognize, diagnose, and treat this disorder effectively.
Considering the short history of BPD as a mental health diagnosis (first introduced in 1980 in the DSM-III), it makes sense, in 2014, for clinicians to first ask to what degree viewer interpretation of this 1987 film drives the film’s available BPD analysis, as opposed to the film or psychological knowledge driving the analysis. As it turns out, the film’s “analysis” of BPD is almost non-existent, with little to no psychological content offered. Fatal Attraction’s fairly simple plot relies heavily on exaggerated affect and the dramatization of unknowable psychological undercurrents to move the story along. For much of the movie, the audience must guess at the emotional and rational states of the characters. Even when concrete information is presented (Dan finds out that Alex’s father did in fact die when Alex was young; Beth tells Alex to leave her family alone), interpreting how the characters, namely Alex, process the information is mostly a guessing game for the viewer. (What motivates Alex to lie about her father’s death? How does Alex feel after Dan tells Beth about the affair?) This interpretation-rich environment leaves ample room for bias that may already exists in the audience to contribute to how we make sense of the inner world of the film and its characters. As viewers of this drama, we bring all of our self-interest and conditioning to bear on our critique of Alex, and in turn, on our understanding of BPD via the Alex character.
Importantly, the considerable room the film leaves for audience bias matters as an initial indicator of just how much the viewer may be making up meaning about the characters based on prejudgment. Even the most basic elements of the storyline must be conveyed carefully so as not to distort the facts: Dan, a (happy? successful?) lawyer is married to Beth, a (stylish? attractive?) mother of one. Dan has an extra-marital affair with Alex, an (enchanting? unpredictable?) editor. When Dan (finally? angrily?) breaks things off with Alex, she displays a number of behaviors (ranging from annoying to frightening?), including—we must actually infer—killing Dan’s daughter’s bunny rabbit. The movie ends with Alex attacking Beth in her bathroom. Ultimately, Dan and Beth kill Alex. Any of the above parenthetical details might be considered important and good writing for advertising copy for the film in order to elicit interest from a known, culturally-situated audience so that we the consumers will be inclined to pay to watch it—“know your audience” as the adage goes. These same details if included but left unconsidered, could contribute to clouding the clinician’s ability to accurately recognize, diagnose, and understand BPD or to hold the empathy needed to treat a client with BPD. Indeed, with a little further digging, it becomes clear that the weight of our viewer bias is really quite heavy.
A specific area of potential viewer/therapist bias that deserves deep and broad ongoing critical attention is sex and gender. The critical step of considering sex and gender in Fatal Attraction, a Hollywood-ized depiction of mental illness, must be the responsibility of any professional using the film to speak accurately or usefully about BPD. To take this step, we must look closely at how the sexist and gendered filters available to viewers of the film—all of us—may be present in us when considering Alex as a case study for BPD and also how these filters may distort how we learn about BPD and how we approach BPD clinically, both for diagnosis and for treatment.
Despite the larger problem of viewer bias, in 2011, Francine Goldberg published the second edition of Borderline Personality Disorder: A Case Study of the Movie Fatal Attraction, which aims to map Alex’s character and behaviors in the film to “clues” and “evidence” for a teachable case of BPD. Goldberg’s lesson plan, now easily accessible on the Internet, has been lauded by the Employee Assistance Professionals Association (EAPA) as, “a unique teaching method that allows EA professionals and other clinicians to acquire clinical skills and earn PDHs and CEUs” (p. 1). The EAPA cites some evidence for the effectiveness of Goldberg’s work as a teaching tool, but offers no critical framework of Goldberg’s analysis. While it may be true, as the EAPA reports, that after seeing the movie and discussing it, “EA professionals had acquired a more sophisticated understanding of psychopathology and were more likely to refer individuals with psychiatric symptoms to a psychiatrist or a specialized counselor” (p. 2), at what cost do these gains come? Perhaps it is simply easier to keep graduating students, handing out certifications, and not looking too closely at this question—yet looking closely is certainly what clinicians must do.
In making her case for a BPD diagnosis in the Alex character, Goldberg (2011) asserts early on that, “People with BPD cannot tolerate being alone” (p. 12). Elaborating on this point, Goldberg cites Synopsis of psychiatry, behavioral sciences, clinical psychiatry: “To assuage loneliness, if only for brief periods, they accept a stranger as a friend or are promiscuous” (Kaplan & Sadock, 1991, p. 534). Goldberg’s mapping of Alex’s character to the DSM-IV’s criterion #4 for a BPD diagnosis, impulsivity, subsequently hinges largely on a prejudgment of Alex’s sexual behavior as “promiscuous.” Goldberg (2011) notes the following: in scene two, Alex shows, “interest in a man who is (a) married and (b) has not really expressed an interest in her which may be indicative of criterion #4, impulsivity” (p. 9); in scene three, “seducing a man that she barely knows and who is not available for a relationship with her may be indicative of criterion #4, impulsivity” (p. 11); and in scene eight, “the news that Alex is pregnant is additional evidence to support criterion #4. Not only did she have sex with an unavailable man that she does not know, the sex was unsafe” (p. 25). In all three instances, Goldberg’s conclusion that Alex is “promiscuous” is the central (and really only) argument for Alex meeting the DSM-IV’s criterion #4 of BPD, impulsivity. Consider Goldberg’s assessment again in sum: Alex, the potential BPD client, is interested in a married man, who does not overtly share back about his interest in her, seduces him anyway, even while she also barely knows him, but does know that he is already “taken,” and chooses unsafe, condom-less sex on top of it all. As Janet Wirth-Cauchon noted back in 2001, “No mention is made of Dan’s ‘impulsivity’ in doing the same with a woman that he barely knows” (p. 170). But beyond this one-sided view of the sex shared by Dan and Alex that Goldberg continues to espouse in 2011, notions such as female seduction, adultery, sexual ownership, and sex as a weapon (tricking a man into pregnancy) are deeply entrenched sexist attitudes that exist in contemporary cultures, including our own, and that have been relied on to control female sexuality and female choice. Surely, these attitudes in ourselves must be considered before applying them to criteria for diagnosing BPD in any client.
Indeed, it is unclear after uncovering the sexist trope of “promiscuity” so readily available to us, whether Alex having sex with Dan is impulsive behavior for Alex at all. Though that is exactly the inquiry that a clinician would need to make with a client before diagnosing BPD. We do know that in the seduction scene Alex offers that she is trying to make up her mind about sleeping with Dan, which could be a “clue” (using Goldberg’s system) that Alex is in fact strategic about choosing her sexual partners—the opposite of impulsive. Interestingly, Goldberg (2011) also notes that for a diagnosis of BPD, “the symptoms must be pervasive, not just in response to one relationship or one event” (p. 11). But from the film we know of no other lovers who Alex has “promiscuously” (read: “impulsively”) slept with.
It is also worth noting that the DSM-IV criteria for BPD, used by Goldberg, refer to sex only once; criterion #4 states, “impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)” (APA, 2000, p. 710). (The DSM-5 criteria for BPD do not mention sex at all.) The sexist trope of “promiscuity” that Goldberg relies on to demonstrate DSM-IV criterion #4 in Alex’s behavior, therefore, assumes that non-monogamous, casual sex is not only impulsive behavior, but is also unhealthy and maladaptive. Not only, then, must we ask if Alex’s sexual behavior is impulsive for Alex, but we must also consider what the potential her sexual behavior in fact creates for self-damage, or if this is also Goldberg’s prejudgment. To what degree the sexual tryst shared by Alex and Dan was an act of self-damage by Alex may also be an important question for the plot of the film. But let us not get those two inquiries confused!
Let’s look at Alex’s own words for a moment: “Because I won’t allow you to treat me like some slut you can just bang a couple of times and throw in the garbage? I’m gonna be the mother of your child. I want a little respect.” Is it worth at least considering that in a world where women are often left with impossible choices to make, they may face their non-rational circumstances with non-rational attempts to reclaim their power? Dan, having participated in the condom-less sex, offers no emotional support or legitimacy to Alex’s position upon learning about the pregnancy. Of course, by this point in the movie we wouldn’t expect him to do so. The movie has made a hard turn toward following Dan as the primary sympathetic character—it is Dan who we sweat with whenever the phone rings; it is Dan who we rush to the hospital with when Beth gets in a car accident; it is Dan who we beg with for help from the police. And Dan does not want Alex in his life, so neither do we. Though the movie stays close with Dan, is it at all possible for the clinician—for any of us—to imagine that Alex’s attacking behavior is not so much self-damaging, an element of BPD, as Goldberg argues, and rather a non-rational attempt by Alex to wrangle some power from her spiraling situation? And if we cannot consider this, why not?
Goldberg seems knowingly convinced that at every step in the entanglement and the unraveling of the affair that Alex is actually compelled to make choices that create situations that are harder on her. This is not relegated to her sexual behavior alone. Per Goldberg (2011), Alex displays, “undermining of self,” “recurrent self-injury,” “constant state of crisis,” and “self-mutilating behavior” (p. 4–6). All of this self-damaging behavior adds up to an overall inability to self-regulate. In fact, it is important for Goldberg’s case for a BPD diagnosis that we view Alex’s tendencies to self-damage as a strong indicator of a larger pattern of being emotionally out of control, aka hysterical. For Goldberg, in fact, the main evidence for a diagnosis of BPD is Alex’s “emotion dysregulation” (2011, p. 22), which Goldberg suggests may have its origins in Alex’s father’s death when she was very young. There is no further mining of the origin of Alex’s BPD, however, either by Goldberg or in the film. Instead, the film’s focus (and Goldberg’s) is on the reel-time execution of Alex’s “madness” in and after her affair with Dan. As Wirth-Cauchon (2001) notes: “The maneuver is the age-old one of dismissing righteous female wrath as hysteria, and by ignoring it, transforming it into actual hysteria” (p. 172).
Perhaps further illuminating is the fact that, when trial screened, Fatal Attraction had a different ending. The film’s first audiences were also left to grapple with Alex’s death, but in the original version she dies by her own hands, slashing her throat with a kitchen knife like the one she used previously to attack Dan. Dan is then arrested for Alex’s murder. The discomfited, even angry response from these first viewers, who having to deal with Alex’s suicide and Dan’s apparent punishment for his part in Alex’s downfall, however, may have prompted the producers to change the final scenes. Whatever the causes of the changes, the new ending ensures that at the final curtain the complex, nuanced experiences of BPD do not live and breathe in Hollywood’s captivating melodrama. In the end, the vast majority of Fatal Attraction’s viewers were given a more familiar, culturally relatable ending of sane, male good guy versus mad, female bad guy. As Wirth-Cauchon (2001) argues, this is “particularly disturbing” in that “a fictive and misogynist cultural image of a woman is presented as reality, and as an accurate picture of a woman with borderline personality disorder” (p. 171).
It is truly unfortunate that by using Fatal Attraction to teach about BPD, what we get is a dangerously static story about BPD, a story given to us first by the filmmakers as an option for understanding the character of Alex, and then endorsed and solidified by Goldberg (and others) as useful tool in working with BPD. Goldberg, ironically, is acutely aware that “clinicians often find themselves…judging rather than sympathizing” (2011, p. 39). But Goldberg does not extend this interpretive lens to herself by considering the potential for the sexist and gendered nature of the “clues” and “evidence” she gleans from the film. Nor does Goldberg turn a critical eye on the overly sympathetic position of Dan in the final version of the movie. After all, the movie does not ask us after confronting Alex’s madness to love her anyway; instead, we get to love Dan and Beth who—and maybe because of this—kill Alex. The mad person is stamped out, and Dan and Beth and their representation as peaceful and good members of “normal” society maintain a monopoly on the audience’s empathy.
Even though Goldberg warns her readers that clinicians must be careful to work with BPD clients to be empathetic and non-judgmental, perhaps the most alarming aspect of Goldberg’s case study is a failing to widen the reader’s capacity for empathy by failing to address sexism and gender-typing in the film. Goldberg gets it right when she keenly notes, “empathy is an essential ingredient in delivering mental health treatment successfully” (2011, p. 38). But if we continue to see people with BPD as villains, can we also see them as ill and deserving our empathy? At present, the best treatment known for BPD, dialectical behavior therapy (DBT), is built on the clinician’s capacity to empathize with the client. To be empathetic one must be able to “be with” someone else’s experience in a loving way. Fatal Attraction does not offer this experience to the viewer with Alex; if anything it offers us empathy with Dan. By missing out on critiquing sex/gender and other potential biases in Fatal Attraction, it is almost as if Goldberg is admitting defeat to what is possible for how deeply we can go with empathy for the BPD client—Hollywood does it good enough. For clinicians that is a catastrophic lesson.
If Fatal Attraction continues to be used to teach about BPD, it seems necessary at the very least to include additional attention to and information about the lenses of sexism, gender typing, and accurate, non-judgmental empathy for the client at every step of the analysis. In order to be an effective therapist for a person who may be diagnosed with BPD, like any mental health diagnosis, uncovering potential bias in the diagnosing clinician and in the proposed treatment plan is mandatory. Likely the most important bias that we must overcome for folks with BPD is our own capacity for empathy, which may come about for varied reasons, not least of which may include sexism and gender stereotypes. Even Glen Close, who has apologized for her portrayal of mental illness as directly linked to violent crimes, might do well to extend that apology to include the misguided, potentially disastrous notion that mental illness may be somehow fundamentally un-empathetic.
American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington D.C.: American Psychiatric Association.
Clyman, J. (2012). Young Adult: The new borderline personality disorder in cinema. Retrieved from http://www.psychologytoday.com/blog/reel-therapy/201203/young-adult-the-new-borderline-personality-disorder-in-cinema
Employee Assistance Professionals Association. Counselor creates unique multimedia method for acquiring clinical skills. Retrieved on December 7, 2014, from http://www.eapa.info/ChaptBranch/webdocs/Beneficial1108.pdf
Goldberg, F. R. (2011). Borderline personality disorder: A case study of the movie Fatal Attraction. Retrieved from http://img-srv.dtcbuilder.com/engine/Builder/images/2/9/0/8/6/0/file/7.pdf
The Guardian. (2013). Glen Close says sorry for her portrayal of mental illness in Fatal Attraction. Retrieved from http://www.theguardian.com/film/shortcuts/2013/jun/05/glenn-close-apologises-mental-illness-fatal-attraction
Kaplan, H. I., & Sadock, B. J. (1991). Synopsis of psychiatry, behavioral sciences, clinical psychiatry, sixth edition. Baltimore: Williams & Wilkins.
Wirth-Cauchon, J. (2001). Women and borderline personality disorder: Symptoms and stories. Rutgers University Press: Piscataway, NJ.