Fasten your seatbelts, ladies and gentlemen! Rebecca was given a “definitive” “diagnosis” in this episode. If you know anything about the diagnosis, and if you’ve read anything written by me before, you might be able to guess how I feel about borderline personality disorder.
Let’s get on with the recap, while I try to hold Metamaiden back from turning this post into one long rant about the horrors of the borderline personality disorder diagnosis and the ways it’s overdiagnosed in women, and used to control us, especially when you disagree with your elderly psychiatrist, who probably shouldn’t even be practicing anymore, as evidenced by the fact that he prescribes one medication after another that’s contraindicated for your serious chronic illness and gets defensive when you refuse to take those medications**; or your middle-aged male psychologist who decides that your near death experiences due to your illness aren’t trauma, they’re just white girl problems, while being completely sympathetic to your brother’s trauma from watching you suffer; or your middle-aged female counselor who tries to diagnose you when you’re a teenager despite that being expressly excluded in the definitions of the diagnosis.
There was a very good reason why Rebecca didn’t like what she found on the internet when she looked up her diagnosis. It’s the “my doctor doesn’t like me and thinks I’m difficult to work with because I’m a woman who questions them” diagnosis.*
Then there was the way Rebecca’s new doctor acted like a withholding, patriarchal jerk with a God complex. She has a right to her own medical information, thanks. If you don’t want an intelligent woman to search out more information on her own, like any normal person would, then be a responsible professional and give her the information yourself. Don’t treat her like a child. And don’t exploit her pathological need for approval from authority figures and good looking men, either. That’s completely unethical.
Rebecca is in the hospital in LA, or maybe West Covina. Paula is hovering in the room, because Rebecca is on her 72 hour suicide watch. Heather and Valencia are out in the waiting room. Josh rushes into the waiting room to see Rebecca, because now he feels bad about their most recent fight. We’re all left speechless for a moment. Josh’s guilt baseline is: If my ex-girlfriend nearly dies, I have to reassess whether or not I went too far. Paula chases him out before Valencia can sharpen her knife.
Rebecca meets with Dr. Akopian. Rebecca’s still sure that she’s let everyone down and they’re all mad at her. Dr A and Paula tell her no, it’s all fine. She was brave to ask for help. Dr A gives Paula the evil eye for hovering too much.
Nathan’s at work, trying to send Rebecca flowers, but he can’t get the message right. George is organizing a cupcake basket from the office. Heather brings Hector to the hospital with snacks to share for their 3rd date. Val and Hector have a frenemies moment. Val gets blamed for being a b*tch when Hector started it. This is not okay.
Val makes Facebook videos for Rebecca’s friends. Hector ruins them whenever possible, but somehow Valencia comes out as petty for being upset. She might have a personality disorder, too.
Rebecca’s getting ready to go home. The insurance won’t pay for much time in the hospital, so off she goes, no matter how unready she feels. In the US, the insurance company is the ultimate arbiter of your care, and your employer chooses your insurance company.
Rebecca’s new psychiatrist, Dr Shin, stops by to tell her that she has a new diagnosis. He believes that she’s been misdiagnosed all these years. He wants her to stop by the clinic before she goes home.
Ah, the smell of a shiny, new, unspoiled diagnosis in the Springtime! Whoever wrote this song has had, or knows someone who has had, the experience of taking years, and many doctors and misdiagnoses, to get the accurate one.
People with hard to diagnose chronic illnesses everywhere can relate.
Rebecca: Diagnosis time! Hit me!
Dr Shin: (Speaks in a monotone throughout.) It’s important to keep in mind that nobody’s diagnosis is simple or covers everything.
Rebecca: Yep, yep, yep, yep.
Dr Shin: It’s also important to not look up the diagnosis online before we have a chance to get into it. Okay?
Rebecca: Got it. I will not look up anything if you don’t want me too. I’m a good student. I will stick to the required reading, sir! (Salutes him.)
Dr Shin: Rebecca, I am noticing how energetic you are. That’s not uncommon after a suicidal event.
Rebecca: (Soft voice.) Too energetic. Sorry. Sorry. I’m sorry. I’m calm now. This is my calm low voice.
Dr Shin: (Relaxes back in his chair) Based on my conversation with Dr Akopian and our meetings at the hospital, it is my belief that, while you do have some symptoms of anxiety, OCD, depression and possibly PTSD…
Rebecca: Right, but I’ve heard all those things before and you said this was a new thing.
Dr Shin: I’m still talking.
Dr Shin: It is my opinion that you exhibit many of the characteristics of borderline personality disorder.
Rebeca: Wow. Ok. First question. What is that?
Dr Shin: A person with BPD is essentially someone who has difficulty regulating their emotions. Someone who lacks the protective emotional skin to feel comfortable in the world.
Rebecca: Wow. Just a couple questions. How did I get BPD? Is BPD curable? How serious is BPD? Is BPD easy to fix? Is BPD genetic? Did I get BPD from my mother? I got it from my mother, right? Again, it’s just rapid fire. Just like answer, don’t think about it.
Dr Shin: I never fall for rapid fire. Rebecca, I know you have a lot of questions. I understand. And we’ll talk about it a lot more in your group therapy, where we’re headed right now.
Rebecca: So you’re just going to pull a Yoda and not tell me anything I want to know before I’m ready to know it. Yeah, that’s what this is.
She promptly heads to the ladies room, looks BPD up on her phone, and sees all of the awful things the doctor didn’t want her to see.
Dr Shin very carefully managed and controlled Rebecca during their meeting. He kept his own body very still and his own voice monotone. He chastised her three times, more or less, for being too energetic, for interrupting him, and for asking too many questions. It was subtle, but for an A student like Rebecca, the message was clear. He might as well have yelled it.
Much of the treatment focus for BPD, as far as I can tell, focusses on these kinds of issues. The practitioner seeks to teach more socially acceptable behavior to the patient. He essentially told Rebecca that the lively, intelligent, warm personality that everyone loves her for is too much. That the intelligence and inquisitiveness that make her a star attorney are too intense. She needs to tone it all down and become Stepfordized.
Maybe I’m wrong, and they’ll spend time delving into the way her parents treated her, and how that’s affected everything in her life. Maybe they’ll bring up how she’s actually created a pretty great life for herself in West Covina, with a good job and a strong support system. Then they can discuss the idea that often, trauma survivors put their issues on hold until they subconsciously feel like they’re in someplace safe enough to deal with the emotions.
When Josh left Rebecca, for the first time in her life, she had a community of people around her who loved her and stood by her, ready to take care of her. It’s not really surprising, when you think about it, that the floodgates of her past abuses would be triggered, and she’d be ready to work out those past emotions. Her parents had been right there, adding to her wedding day disaster.
She finally had a mom that she knew wouldn’t reject her, in Paula, and a dad in Darryl, sisters in Heather and Valencia, a potential love interest in Nathan (but no pressure yet), a passle of brothers, friends, coworkers, and acquaintances. That’s a whole village of people to catch her when she fell. And they did.
So, if the doctors prod her thinking in that direction, and help her learn to think of herself as someone who meets her own needs and builds communities and has friends and loved ones and a chosen family and is loved and loves other people and isn’t crazy, she’ll get better.
If all they do is try to resocialize her into their idea of a good girl, and have her focus on how wrong she is all the time, and the mistakes she makes, she’ll become more sure that she’s crazy and can’t function without a crutch.
Of course she needs to get herself together emotionally. But she needs is to develop a core of inner strength and confidence. With some rest and therapy that she’s open to, I don’t think it would be that hard, now that she’s accomplished so much in West Covina, and she can see it. She might want years of therapy to help keep her head on straight, but I think her basic sanity would be back soon, with relief from the crazy pressure she’s been putting on herself.
What I’m afraid is going to happen is that they’re going to focus on superficial emotions and behavior.
Also- “BPD patients lack the protective skin to function in the world”– That makes patients sound like either infants or skinless monsters. Both are awful descriptions for an adult.
Valencia makes another video for Rebecca’s followers. She’s very perky. Heather breaks in to note that they had to get rid of all of the knives before Bex comes home, as one does after a suicide attempt.
Paula brings Rebecca home. Rebecca is crying because of her diagnosis. Yeah, been there, done that. Nothing like getting a misogynistic diagnosis and a lecture from a doctor about your faulty personality, to ruin your day. Welcome to the world of women’s health care.
Rebecca skipped her group therapy. She was too upset. This is why the doctor should have just answered her questions instead of being a control freak. It’s her health, her body, her diagnosis, her right to information. She’d been waiting 30 years for a name. Of course she needed to know more right away. And she had the right to be given the information in private, where she could digest it on her own.
But the doctor wanted to give her the information in front of people so that they could manage her response. If she was in front of people, she wouldn’t be able to respond honestly, like she did in the bathroom and her bedroom. The other patients would have pressured her into a certain response, and the doctor would have praised her for a certain response (the calm, non-teary one).
No doubt the other patients would have tried to make her feel better about the diagnosis, since they have experience with it, and that would have been a good thing. But, again, there’s no reason the doctor couldn’t have had a fact sheet ready to hand to Rebecca in his office.
This psychiatrist recommends a process very similar to the one Dr Akopian follows when Rebecca goes to her later in the episode, with the addition of a printed information sheet. She finds that respect and trust are very important between doctor and patient from the start, if an ongoing relationship is going to work.
Dr Akopian has been wonderful with Rebecca. Dr Shin was quietly authoritarian and withholding, the exact opposite of what Rebecca needs. She’ll fall into the trap of trying to please him rather than trying to work on herself. Especially since he’s young and good looking. There’s a risk that he’ll become another obsession.
Rebecca tells the girls:
Rebecca: I don’t have an illness, I have a personality disorder. It’s not something I have. It’s what I am. This is what I’ve feared my whole life. I’m broken.
Yep. Everything about the diagnosis is sh*tty, and meant to make you feel sh*tty about yourself.
Paula sensibly suggests a second opinion. A silly D conversation follows. I think the 2nd diagnosis idea is supposed to be OTT, but they run right out to Dr Akopian’s house for her diagnosis.
Valencia now has sponsors (shout out to Shimmer Glimmer Cosmetics!) and a worldwide audience for her updates on Rebecca’s progress. Heather judges but doesn’t judge her pathetic and basic materialism and famewhoring. Valencia isn’t like that, she explains. She’s answering a certain call. It’s a movement:
Her movement is much more important than answering a suicide hotline. She’s all about the inspiration.
Gabrielle Ruiz has a great voice on her first solo.
Dr Akopian is with Kevin, the Home Base owner, who’s super happy and lucky and well-adjusted and feels guilty about it all because other people don’t have what he has. He has no lingering issues from his parents murder-suicide. NONE. So he’s willing to give Rebecca his appointment. That’ll come back to haunt us.
Rebecca and Paula sit down on the couch and demand a new diagnosis, instead of the one that Dr Shin mansplained her into. Dr Akopian gets in a jab at Paula for her constant presence in Rebecca’s life.
Josh corners Hector at Sugar Face and asks for the truth about what Rebecca’s saying about him. He knows that the suicide attempt must have something to do with him. It’s a Cardinal sin, so he needs to get going with his atonement. Hector explains that no one is talking about him, and a suicide attempt is really more of a general mental health symptom. Turns out Josh doesn’t know who he is if Rebecca isn’t obsessed with him.
Dr Akopian chastises Rebecca for breaking the rules and looking up BPD, because Rebecca must be treated like a child at all times now. She gets out the BPD diagnostic checklist. 5 out of 9 are required for diagnosis. Rebecca feels that she has all 9. (The list is near the bottom of this post.) Rebecca is convinced, and drags herself home with her tail between her legs.
She tells Heather and Valencia that she’s certifiably crazy. She goes to bed. Alone. No Paula to keep an eye on her.
Nathaniel hasn’t been able to figure out what to say to Rebecca for the entire episode. He freezes up every time he tries to write something, and pictures his mother passed out on the floor with a bottle of sleeping pills, when he was 10 years old. He finally gives up and confronts his parents about it. They refuse to talk, insisting that the story they told him when he was ten about his mom having the flu and going sailing for a month was true. Nathaniel leaves, unsatisfied.
He goes back the next morning, after his father has left for work, to confront his mother alone. He tells his mom that he loves her, and the roses in her garden look good this year. She breaks down and tells him that, when he was ten, she was having a hard time and accidentally took too many sleeping pills. She went to rehab for a while, then she was okay. She offers to let Nathaniel take some roses for Rebecca.
Paula, Heather and Valencia have had a slumber party on the floor outside of Rebecca’s bedroom door. It looks very cozy. Rebecca picks her way through to the bathroom. Val remembers that she left her industrial strength nail clippers in the bathroom, and everyone panics that, OMG, Rebecca will use them to clip an artery or something. They knock on the door, but Bex doesn’t answer.
Heather gets her murder ax and is about to chop down the door when…Rebecca opens it. She’s fine. She had earbuds in and was listening to the theme song.
Valencia bursts into tears. She was so scared that Rebecca was going to be dead. She doesn’t want to lose Rebecca. She wants Rebecca to promise that she won’t attempt suicide again, but Rebecca says that she can’t promise that. Now that Rebecca knows what she has, she’s going to work on herself, but she can’t promise anyone anything, including herself.
Valencia was using her ever more elaborate video updates as a coping mechanism. She was probably trying to convince herself that everything was okay as much as her worldwide audience. In reality, she was devastated that she’d almost lost Rebecca, and terrified that she could still lose her. Valencia has had very few close friendships in her life, so Rebecca is especially important to her. She kept the depth of her feelings from Rebecca for as long as possible, but it was healthy for her to have that release eventually. Rebecca was past the worst of her crisis at that point and could handle Valencia’s emotions. It was good, in the long run, for her to know how much Valencia cares about her, since she doubts her relationships so much.
Just then, a very sunburned Darryl bursts through the door looking for Rebecca. He was in the yurt with WhiJo and heard what happened with Rebecca. He jumped in a neighbor’s convertible and drove all the way home without sunscreen to make sure she was okay.
Rebecca apologizes to him and everyone for everything she said before she went to Naomi’s and there’s a group hug. Darryl blames the whole debacle on Josh Chan and starts planning what he’d like to do to Josh.
Josh walks up to the open front door with a puppy in his arms, and overhears Darryl. Rebecca stops Darryl and says that Josh is irrelevant. She hasn’t thought about him in days. It’s almost like it’s not about him. Maybe it never was.
Josh turns around and walks away. Good idea. A dog is a terrible gift idea, unless you’ve cleared it ahead of time. Especially for someone who can barely take care of themselves right now.
Rebecca tells Dr Shin that she’s ready to start treatment, including group therapy.
After therapy, she has a therapy workbook. She runs into Nathaniel dropping off his mother’s roses and a meaningful note. They have a moment. He also brings back her giant stuffed alligator, Ruth Gator Ginsburg. Nathaniel is well on his way to becoming a real boy. Josh hasn’t even started the trip.
It’s important to remember when dealing with mental health issues is that mental health professionals see themselves as gatekeepers for social norms. Whether they acknowledge it or not, even to themselves, there is a certain amount of value judgement involved in any mental health diagnosis. Those values are based on what the professional views as the norms and standards of their society, and how flexible the professional is in their interpretation.
There was a famous set of experiments done in the early 1970s known as The Rosenhan Experiment, in which Stanford University psychologist David Rosenhan showed that even the best psychiatric hospitals couldn’t tell the difference between who had mental illnesses as severe as schizophrenia, and who were healthy patients.
Today, mental health professionals argue over whether, and how much, to allow the hard sciences, such as neuroscience, a voice in their discipline, if the current diagnoses carry any weight at all, and if better ways can be found to combine disciplines and improve care that leave out the biased subjectivity of some diagnoses:
We could use biologically driven language in our formulations of mental illness. The language we use sculpts how we consider problems and, therefore, the types of solutions we develop for those problems. Words such as “thought” and “mood” rather sloppily ignore underlying brain processes and leave us linguistically unarmed as we approach the organ of mind.– What Do “Emotion” and “Mood” Actually Mean?
While borderline personality disorder currently exists in the ICD (the world-wide manual that’s equivalent to the DSM that we use in the US to diagnose mental illnesses) it’s expected to be dropped in the next edition. India and China, with two of the largest populations in the world, already don’t use this diagnosis:
Yet one line of questioning in Loranger’s work revealed that avoidant and borderline personality disorders were not found in patient groups from India and Kenya, respectively, even though these are two of the most common syndromes worldwide.
Chinese doctors have indeed developed their own classification system, and it does not include avoidant or dependent personality disorders. Should conditions such as these, then, be considered normal just because they are prevalent in a society? That could very well be the case. Norms define which types of behavior are acceptable, so if a certain trait is common in a society, then perhaps there is nothing “wrong” with it, regardless of how it might be perceived elsewhere.
According to several studies comparing cultures, personality disorders occur more frequently in industrial countries than in less developed ones, where closer social connections tend to dominate. In large families or village communities, roles are clearly defined and evolve very slowly, if at all. Like a cocoon, the community ensures that no individual experiences isolation or feelings of uselessness. In contrast, life in the modern, developed West is hectic and uncertain.
The question of whether a common multicultural denominator of personality disorders can be expressed remains unanswered. Until that day comes, diagnosis will for the most part remain open to cultural interpretation.—Abnormal as Norm
- Frantic efforts to avoid real or imagined abandonment (Fear of abandonment)
- A pattern of intense and unstable relationships with family, friends, and loved ones, often swinging from extreme closeness and love (idealization) to extreme dislike or anger (devaluation) (instability in relationships)
- Distorted and unstable self-image or sense of self (unstable sense of identity)
- Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating
- Recurring suicidal behaviors or threats or self-harming behavior, such as cutting
- Intense and highly changeable moods, with each episode lasting from a few hours to a few days (severe mood swings)
- Chronic feelings of emptiness
- Inappropriate, intense anger or problems controlling anger (excessive and frequent anger)
- Having stress-related paranoid thoughts (paranoia)
- Having severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality (dissociative episodes)
- (Dr Akopian lists paranoia and dissociative episodes as one list item)
I want to make it clear that I am not saying that these behaviors don’t exist, or that people don’t suffer when their moods and emotions get to be too much for them, like we saw with Rebecca. What I am saying is that we need to look at why the behaviors exist, when they started, why they started, and how those symptoms can be abated, rather than just teaching women
to be calm and cooperative to control their annoying hysteria to get their intense emotions under control so they stop pestering doctors.
The symptoms on the list are real, scary, and painful for the people who experience them when the listed behaviors are truly extreme. The issue is, how does one quantify what a “frantic avoidance effort” is? I personally have intense emotions, but don’t show them much on the outside. My frantic effort will look very different from Rebecca’s. I generally get accused of not having enough emotions, as a matter of fact, even by my mother, whereas my father tells me I’m too emotional. Which am I? Cold and calculating, or hysterical and manipulative? Neither sounds very nice, but that’s how women get characterized when one of their prominent characteristics is being analytical, like me. I can see all (or most) of the possible scenarios in a situation. Guess what? That makes me a candidate for BPD!! (Being analytical comes off as paranoia in women to some people, for some reason. If I can see the possibility, I must believe it’s going to happen. It can’t be strategic thinking! That’s too threatening!!) It doesn’t take much to decide a woman, or anyone that you don’t like, has gone too far, or is a selfish, scheming b*tch.
(Read that list of symptoms carefully. Some of them mean that you piss off the people around you too much. It’s a very, very subjective scale. It’s just couched in language that sounds objective and observable. “Frantic efforts to avoid abandonment” are not observable, objective behaviors. “Calling, texting, or emailing the object of obsession more than X number of times in a 24 hour period” can be objectively observed and measured. Records can be checked.)
ETA: As I’ve thought more about the episode, I’ve realized that Nathaniel’s subplot serves as a counterpoint to Rebecca’s. Gigi, Nathaniel’s mom, also attempted suicide and got treatment. Now, she’s the perfect calm and compliant woman. She never speaks out of turn, never voices her own opinion, never speaks about anything controversial, uncomfortable, or upsetting in any way. She sits still, in a ladylike manner, and speaks softly. Definitely not energetically. She would never ask rapid fire questions, or interrupt an authority figure, including her husband.
Ironically, when she gets upset, rather than express her feelings, she leaves the room. (Neither man does.) Metamaiden’s ancient, incompetent psychiatrist told her to do the same thing. She wasn’t allowed to be frustrated and grumble about him. Women’s negative or “excessive” feelings are never okay, and if we don’t learn to control and hide them as children, we’re mentally ill and will be resocialized or drugged into it as adults. With a stigmatizing label that will never go away.
Nathaniel has to beg his mother, when they’re alone, to tell him the truth. Even then, she hedges. She’s been trained to keep quiet, and there will be consequences if she doesn’t, possibly self-inflicted. After a while, the critical, punitive voices are inside your head, and you don’t need them on the outside. Just like Rebecca. Now they want to train Rebecca to suppress more of herself.
Nathaniel grew up in a household where the atmosphere was so stifled and controlled, where emotions were so shut down, especially about his mother’s suicide attempt, that he has difficulty relating to anyone emotionally. Even with the growth we’ve seen from him over the last season, he can’t cross that barrier. Talking to Rebecca about her suicide attempt would be like talking to his mother, and his brain won’t allow him to go there.
Even though he doesn’t have obvious trauma, Nathaniel was raised by a controlling, repressive father, and his other role model was his depressed, defeated mother. Nathan’s actually emotionally sensitive, but, like Rebecca, he was taught to ignore all of the signals that his brain and body were sending him about what was right, wrong, safe, scary, etc. They were both taught that their gut feelings, the body’s early warning system, were wrong, so now they tend to be adrift and confused, unable to trust themselves and their decisions.
Like I said up in the recap, they don’t need more repression. They need to learn to trust and be honest within themselves, and to be strong in the face of the constant gaslighting we face in our culture. That’s how someone develops a stable inner core and self-control. However, it does make them harder for other people to control.
I’m once again wondering where the showrunners are going with this. They acknowledged the stigma associated with BPD, but didn’t acknowledge the other issues. They very clearly showed Dr Shin treating Rebecca differently from the way Dr Akopian does, as he managed her instead of being honest with her. I have a bad feeling about him, but it could just be me. Then again, it’s only episode 6. There’s more than half a season left, something’s got to happen.
Some more articles on BPD that I’m too lazy to make look nice:
*Actually, only two of those 3 wanted to diagnose Metamaiden with something. The psychologist truly thought she was just whiny and should stop complaining, the psychiatrist thought she was too angry to work with, and the counselor wanted to diagnose her with at least 3 personality disorders while she was still in high school. That counselor did a lot of work for the public schools as well, and had issues with homeschooling. Beware the gate keepers. We eventually found a wonderful team and the correct treatment plan and diagnosis. Now she’s back to her normal, pretrauma self, for the most part.
Please, please don’t be afraid to question your health care providers, treatments, and diagnosis, even if it means changing providers and being unpopular! Doctors aren’t gods and they aren’t getting their information from a bible. The medical establishment changes it mind constantly, and discovers new information and treatments. Not all doctors keep up and change with the times. It’s important to do what you think is right!
**He retired less than a year later.