David Jones outlines the historical and clinical context in which the diagnosis of ‘borderline’ emerged, citing this context as vital in understanding perceptions of Borderline Personality Disorder today.
This article briefly references self-harm and suicide.
In recent decades, Borderline Personality Disorder (BPD) has emerged as one of the most frequently diagnosed mental health conditions, not only appearing commonly in primary care, accident and emergency, and mental health services, but also in school and student welfare settings, suggesting a broad societal impact (Jones & Lomani, 2023). The term ‘borderline’ has even become part of everyday conversation, entering popular discourse (Cariola 2017) and culture: for example, the film ‘Girl, interrupted’ (1999, written and directed by James Mangold), and in the TV series ‘Greys Anatomy’. The diagnosis is often associated with emotional dysregulation, impulsivity, ‘inappropriate’ anger, volatile relationships, and most notably, self-harm and suicidality (NICE, 2009). Despite its prevalence, BPD remains controversial both within the mental health community and society at large. Wren Aves (2023) spells out the many ways that the diagnosis can be harmful with those receiving the diagnosis experiencing stigma, hostility and a withdrawal of care, rather than treatment and support.
But how can we understand why this diagnosis has become so problematic and even harmful? To understand this, we must look back at its origins and how the cultural and intellectual context of its birth shaped the diagnosis in ways that are now hard to understand. It is argued here that ‘borderline’ emerged as a diagnosis at a time when there were strong intellectual currents that understood mental distress as the result of dynamic psychosocial processes that assumed a continuity between internal states and the social world. The diagnosis of BPD began to appear in psychoanalytic practices in Britain and the United States in the 1930s with the American psychoanalyst Adolf Stern providing what is generally acknowledged to be the first formal definition in 1938, through his discussion of ‘borderline neuroses’. The diagnosis was shaped in the social and intellectual landscape of the 1930s. This was an era in which ideas and practices in social work, psychoanalysis, psychiatry and community therapy were intersecting- and were being informed and shaped by the social and political concerns of the age: marked by economic decline, industrial strife and the looming threat of fascism (Overy, 2009).
The interdisciplinary framework that shaped the emergence of ‘borderline’ is no longer present today, making it difficult for modern clinicians and patients to engage with the diagnosis in the same terms in which it was originally conceived. Indeed, one of the crucial promotional drivers of the diagnosis was its inclusion in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) by the American Psychiatric Association in 1980 (Jones, 2016). Although the various editions of DSM (since the first in 1952) have given slightly different emphasises to various theoretical frameworks (including social, organic and psychological causes of distress), the DSM project has overall shifted psychiatry towards an understanding of distress in terms of individual psychopathology. This shift has not been uncontested, something which becomes apparent from historical accounts of the debates that surrounded the entry of borderline into DSM (Decker 2013). There were two warring factions evident: the clinicians who were influenced by psychoanalytic theory and their own clinical experience versus the researchers who wanted to see psychiatry take a more ‘scientific’ approach.
However, a largely unrecognised issue is the extent to which, what is now taken to be psychoanalytic thinking, was actually a product of far more cross-disciplinary frameworks. This point is well illustrated by the influence of child psychoanalyst Donald Winnicott, who attended a conference organised to smooth the entry of BPD into DSM-III by bringing the two sides (clinical and research) together (Hartocollis, 1977).
The Influence of Winnicott: The Transitional Space
The psychoanalyst Andre Green presented a paper at the conference (Kafka, 1981) and reviewed the various psychoanalytic theorisations of borderline, declaring Winnicott to be ‘the analyst of the borderline’ (Green, 1977). This might appear puzzling because, although Winnicott has been one of the most influential psychoanalysts of our time, he never explicitly wrote about ‘borderline’. He had, however, made significant contributions to debates about ‘character disorders’ which he understood as existing in a space between neuroses and psychoses. Winnicott also saw such ‘character disorders’ as being linked to the experience of challenging childhood experiences (Winnicott, 1984). These links were not what drove Green’s conclusion, however. Instead, he pointed to Winnicott’s development of the concept of ‘transitional space’ as crucial to understanding ‘borderline’: the idea that healthy human development depends on the ability to exist in a world that is constructed in part from the internal world of the psyche and in part from the external world of outer ‘reality’ (Winnicott, 1971). The capacity to create and live within this intermediate space is a crucial developmental task that enables an individual to engage with- and be part of- the human world around them. As Green noted, the concept of transitional space came from a significant shift in Winnicott’s thinking, from a psychoanalytic focus on the internal world of the individual psyche towards a greater interest in relational dynamics and the significance of the environment (Green,1977).
The Role of Hawkspur and Q-Camps: A new client group
Winnicott’s thinking on ‘transitional space’ was significantly influenced by his experiences with a cross-disciplinary experimental therapeutic community called Hawkspur, run by the Q-Camp Committee between 1936 and 1941. The Q-Camp Committee was created by people with experience of various community living experiments that were taking place in the 1930s. It also involved those working in the notably cross disciplinary Institute for the Study and Treatment of Delinquency based in London. Although founded by psychoanalysts, the Institute also included social workers, lawyers, policy makers and social scientists (Jones and Fees, 2023). Hawkspur was located in rural England around 40 miles East of London, and was a residential camp designed to help young men at risk of falling into lives of crime. The camp drew on ideas from psychoanalysis, community therapy, social work, and political activism, forming a rich interdisciplinary framework for understanding personality and behaviour (Jones and Fees, 2023).
The work at Hawkspur, and the ideas emerging from the Q-Camps, were helping to engender a nexus of understanding that fostered the conceptualisation of BPD as it emerged in the middle of the 20th century. The young men at Hawkspur were often described using terms that would later evolve into what we now recognise as ‘personality disorders’. Indeed, terms like ‘psychopathic personalities’ or ‘borderline schizophrenics’ were being used at the camp. Significantly, one young man referred to himself at the time as ‘a person who is called a ‘borderliner’ by doctors (Jones & Fees, 2023).
One of the camp’s founders, the psychiatrist and psychoanalyst Marjorie Franklin, saw the camp as meeting the needs of the ‘maladjusted, adventurous personality’—young adults whose needs were not being met in mainstream mental health services and would be ill served in the criminal justice system. These individuals often had troubled early life experiences, and their behaviours were seen as symptoms of deeper relational and environmental failures rather than purely individual pathology (Franklin,1 971). The idea of community therapy they were developing and promoting was driven by the belief that the pathology should be understood and treated as relational.
Winnicott was exposed to Q-Camp methods when the Q Camp Committee took their approach into a residential childcare project (in Bicester) that looked after troubled children who had been evacuated from the war time blitz (Jones and Fees, 2023). This profoundly influenced his later work on transitional space and the importance of the environment in shaping personality. In his final public talk in 1970, Winnicott reflected on how his time working with the Q-Camps had shifted his understanding of therapy (Winnicott, 1970/1984). He realised that the therapeutic environment itself—the physical surroundings, the structure, and the community—could be more important than formal psychoanalytic sessions. Therapy, he argued, was not being achieved through formal therapy, but was accomplished by the everyday routine and structure of the camp: the cook, the beds, the meals, and the order maintained by the staff.
The Legacy and Controversy of BPD
The historical and intellectual roots of BPD in the 1930s, shaped by transdisciplinary thinking and therapeutic communities like Hawkspur, provides important context for understanding why the diagnosis of ‘borderline’ remains so contested today. As it emerged within the cross-disciplinary context of the 1930s (as exemplified by Hawkspur), the concept of ‘borderline’ was deeply relational, focussing on how failures in the environment and interpersonal relationships contributed to emotional instability. However, cultural shifts of the past 50 years or so have moved us far away from the interdisciplinary frameworks that shaped the original diagnosis. It is now hard for us to comprehend the diagnosis in those terms. Modern psychiatry tends to focus more on individual pathology, often at the expense of understanding how relational dynamics and environmental factors contribute to mental distress. As a result, BPD is now often seen as a disorder defined by its symptoms as they emerge within individuals, and the responsibility for the disorder is assumed to lie within the individual. However, the pioneers who originally developed ideas that nurtured the diagnosis understood ‘borderline’ as residing within failed social relationships.
Conclusion
The ‘problem’ with the ‘borderline’ diagnosis is that it was born out of a cultural and intellectual context that no longer exists. While the diagnosis thrives because it does perhaps identify a specific set of emotional and relational difficulties that have become prominent, it has also become a source of stigma and exclusion. Many with the diagnosis report feeling abandoned by the very mental health systems that are supposed to help them.
To begin to address the needs of those labelled with BPD, perhaps we need to move beyond the narrow behavioural definitions that have come to dominate modern psychiatry and instead view ourselves through the relational and environmental frameworks that originally shaped the ‘borderline’ concept. By doing so, we might provide more compassionate and effective care for individuals and even reclaim the original spirit of interdisciplinary collaboration that gave rise to the diagnosis in the first place.
About the author
David W Jones is Senior Lecturer in the School of Psychology at The Open University. He has long standing interest in the diagnoses of personality disorder and published ‘Disordered Personalities and Crime: An Historical Analysis of Moral Insanity. (Routledge 2016).
He is Joint Editor of the Journal of Psychosocial Studies, and founding member and Treasurer of the Association for Psychosocial Studies.
References
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Jones, D.W. and Fees, C. (2024) ‘The story of Hawkspur: a transdisciplinary project’, International Journal of Therapeutic Communities, in preparation.
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