On 'Throwing Around Diagnoses'
Published on 9.25.2023 at garyborjesson.substack.com
We all do this, we all throw around diagnoses. - Comedian Marc Maron
Imagine you’re at a party and a guy tells you he used to be “a little borderline”—shorthand for reactive and emotionally unstable. Now imagine you saw a person across from you cringe upon hearing this. Why did they cringe? Should you cringe?
Something like this happened to the comedian Marc Maron. After his podcast episode featuring a conversation with fellow comedian Maria Bamford, a listener wrote that they were concerned to hear Maron say that when he was younger he was “a little borderline”. Maron graciously took the listener’s concerns seriously enough to air them on episode 1467.
So, what’s wrong with Maron saying, “When I was younger I was a little borderline”? Why were he and Bamford cautioned for speaking causally, even jokingly, about their mental-health issues? What assumption made the listener feel they had the authority to advise Maron and his listeners against using diagnostic language thus?
There are several issues at play here, including matters of free speech, but I won't be wading into those (shark-infested) waters here. Instead, I want to explore the assumption about mental illness that motivates the listener’s concern, and look at why it’s false.
The assumption came out in the listener’s claim that a personality disorder is “something intrinsic to your being”. Practically speaking, this means that if you’re diagnosed with a personality disorder you’re largely stuck with it. But while personality disorders can be difficult to treat, this is not because they are intrinsic to the person’s being. As I pointed out in my last note, on diagnosis and human experience, being emotionally unstable and behaving narcissistically are human experiences. This is why Maron is speaking accurately when he says he used to be “a little borderline.” What distinguishes people diagnosed with personality disorders is the severity and duration of their experience, not its uniqueness. The listener may have been misled by the DSM’s categorical system of classification into thinking that personality disorders are like being pregnant, either you have it in you—it’s “intrinsic”—or you don’t. In fact, these experiences lie on a continuum.
Before looking at the deeper reason why personality disorders are not intrinsic, let’s first unfold what the listener thought followed from their assumption. If a personality disorder is intrinsic, the reasoning goes, then to speak of it as something you could have a “little bit” of, or as a phase you could go through, is to speak falsely. It risks giving “false hope” to those so diagnosed: they might imagine change is more possible than in fact it is. They might end up feeling ashamed they aren’t able to change. The listener also worried that speaking as Maron and Bamford had risked “diminishing” how seriously people take such diagnoses. Presumably the worry is that people might think of personality disorders the way we used to think about addiction—as coming down to a matter of willpower. In that case failing to overcome a personality disorder could be viewed as a moral failing—as if someone just didn’t try hard enough to change.
To the contrary, the observation made in “About Addiction” applies here: the cause and treatment of most mental disorders has such a strong developmental and interpersonal component that it makes little sense to blame or shame the individual for their problem. This expresses the deeper reason why personality disorders are not intrinsic. Like most disorders, they are not intrinsic to us, and there is no evidence they are “in the genes”. Rather they emerge from a complex interplay between nature and nurture, between the individual and their environment. This rules out viewing it as intrinsic, either in origin or with regard to treatment.
That said, some, if not many, clinicians share the listener’s assumption. But this says more about the time it takes for current research to trickle into mainstream thinking.¹ The fact that we’re only beginning to appreciate the extrinsic factors informing mental illness is part of why we’ve been so bad at treating mental health problems, including addiction and personality disorders. We’ve been looking in the wrong place. Treatment is more effective (though not easier) when we view mental health in the context of the interpersonal field through which it exists.
So, there’s no good reason to cringe when Maron and Bamford (or any of us) use diagnostic language to help describe their experience. Assuming that, like Maron, we’re sensitive and aren’t seeking to push buttons, the language offers us a shortcut, a useful map to the territory of human suffering. I am also assuming here that it’s reasonable to expect that adults not take personally what’s not meant personally. Taking responsibility for our feelings means recognizing that being triggered by others doesn’t necessarily mean they’ve said anything wrong. That’s a lot to ask in our current hypersensitive culture, but it’s part of being a grownup, and of living in a society committed to tolerating free speech.
Again, Dr. Gabor Maté’s most recent book, The Myth of Normal, exhaustively documents the critical role developmental and interpersonal factors play in mental health.