I was hoping that my work with Jacqueline would help her quickly achieve stability so she could feel safe at home again. At our third session she told me that she wanted to be admitted to the hospital but wanted to wait until her mother got off work. I wasn’t entirely comfortable with this, but my supervisor gave me the go ahead. Fresh out of graduate school, I tried to engage her in a mindfulness exercise I had learned and thought would be helpful. We made it through two minutes before she begged me to stop. The demons she was hearing in her head were too loud. She had seen them leering at her in the waiting room, and they were now infiltrating her thoughts. She tried to resist them, but it became overwhelming.
Jacqueline did go to the hospital the next day. As I mentioned earlier, this became a pattern over the next year. Each time we concluded a session I checked her suicidality, but it seemed to vacillate wildly from day to day. I knew I couldn’t hospitalize her forever. Instead I began to work with her to find out what she liked so much about being there.
I have been on our hospital’s psychiatric floor several times to see my patients who are recovering there. It is a necessary place, of course, but also a deeply sad one. Our hospital building is very old, and to access the ward you must first walk along a narrow corridor with yellowed windows that open on the city skyline. There’s a faded shuffleboard court painted upon the tiles lining the walkway, a vestige from a different era. It looks like something out of One Flew Over the Cuckoo’s Nest. The rooms are small, airless. Each has a sink with a sheet of polished metal firmly latched to the wall to serve as a mirror, but age has dulled it to the point that you can barely make out your features. The television is on, loudly, in the common room. Someone is usually yelling. I always stop by the soda machine to treat myself before walking back to my office. It’s become my ritual, and not because I need the caffeine. The place is so depressing I need something to jolt me to my senses and provide a little mental distance before I resume my regular work.
That was what I saw, but that was not how Jacqueline experienced it. For her, it was a wonderful place to be. “I wish I could just live at the hospital,” she told me. She felt safe there. She enjoyed engaging with others in groups there even though she resisted attending groups in the outpatient clinic. She found the staff to be warm and affirming. She was never alone.
Jacqueline made great efforts to avoid feeling abandoned. She had a series of intense, short-lived relationships. She wasn’t quite sure who she was. She had made several attempts at suicide and frequently thought about it. She had difficulties controlling her anger. She often felt empty. Many professionals had looked at that list and diagnosed Jacqueline with borderline personality disorder (BPD). In one sense, they weren’t wrong; that list of the symptoms matches precisely with the DSM-5. BPD would be convenient in that it would capture her symptomatology, yet I never felt comfortable assigning her the diagnosis for a few key reasons.
Personality disorders are a strange beast. The DSM-5 defines a personality disorder as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” We don’t think of depression as being “pervasive and inflexible”; even more serious mental illnesses like schizophrenia are fairly capable of being managed. There is no drug, no cure for a personality disorder. It simply names who you are.
A diagnosis of borderline personality disorder comes loaded with even more baggage. I have heard colleagues usually dedicated to person-first language (e.g., “person with schizophrenia” rather than “schizophrenic”) refer to patients with the diagnosis as “borderlines.” A recent bestselling self-help book written by a psychiatrist described dating people with BPD as “addictively exciting, and it’s hard to say no to a girl who’ll jump your bones in a bathroom stall, or accept a dare to flash a cop, or drink you under the table. At least until she kills your dog … a borderline is many things, but she is most often known as the reason men think all women are nuts.”1 A 2015 study2 found that psychiatric nurses had less empathy for patients with borderline personality disorder than those with other mental illnesses, and psychiatrists were less likely to recommend hospitalization for suicidal ideation if a patient had borderline personality disorder. These negative attitudes actually increased the more one had professional contact with a person with BPD.
Borderline personality disorder is also a gendered diagnosis. The DSM-5 notes that 75 percent of those diagnosed with BPD are women even though the symptoms appear to be equally present regardless of gender.3 Childhood trauma is experienced by the majority of those diagnosed with BPD, and the more severe the trauma, the more pronounced the symptoms.4 The symptoms of BPD seem eerily similar to the antiquated notion of hysteria, so named because it was thought that it was caused by a shifting uterus. (Hysterika is Greek for “uterus.”) As hysteria faded into the background, BPD took its place. The diagnosis combined with the stigma often leads to women being punished for their response to abuse and assaults. It’s like inventing a diagnosis of acute gunshot disorder without investigating who fired the weapon.
Jacqueline’s identity as a transgender woman made the diagnosis of BPD even more punitive. It did not seem fair to Jacqueline or the rest of the transgender community to blame her for suffering the hatred and intolerance of the rest of society. As far as I could see, Jacqueline felt thrice rejected: by the culture at large for being Latinx, by her Latinx culture by being LGBTQ, and by the LGBTQ community by being a trans woman of color.
Not feeling safe in your neighborhood can be a function of mental illness, a response to the real threat of community violence, or both. I believed Jacqueline when she said that it wasn’t always safe for her to go outside dressed as a woman. According to the Human Rights Campaign, in 2017 at least 28 transgender people were murdered in the United States. (Many victims are misgendered in media and police reports, which suggests that the actual figure could be much higher.) Trans women of color are at an even greater risk of violence.5 Two trans women were killed in Chicago in the span of six months while I was treating Jacqueline. On September 11, 2016, the body of T.T. Saffore was found near railroad tracks in West Garfield Park. Tiara Richmond (also known as Keke Collier) was shot in Englewood on February 21, 2017.6 Jacqueline unfortunately had good reason to fear for her life every time she walked out her front door.
Chicago has several neighborhoods that are home to a significant LGBTQ population where Jacqueline might feel safer. Perhaps the most notable is Boystown, home to many of her favorite memories from the time right after she had come out.7 Chicago’s gay enclaves used to be located closer to the downtown area, but as rents increased in the late 1960s and early 1970s LGBTQ nightlife shifted north to occupy a stretch of Halsted Street. For years, Boystown was the epicenter of the annual Pride Parade and home to a variety of nonprofits that served the gay community, and in 1997 Mayor Richard M. Daley officially recognized Boystown as Chicago’s gay district, installing large rainbow-colored pillars throughout the area. Boystown has steadily gentrified as societal acceptance of gay people increased, and the neighborhood is now often criticized for being very white and catering almost exclusively to gay men.
Boystown was where Jacqueline first found herself as a gay male, and she often wished to return there to live. She knew that she risked judgment as a trans woman of color, but it still felt safe to her. Years of rising rents had priced her out of the neighborhood, though, and most of the other LGBTQ-friendly neighborhoods in Chicago are similarly out of her reach. Like many of my patients with serious mental illness, Jacqueline receives federal disability payments each month, which serves as her primary source of income.
“Disability” is somewhat of a misnomer; the same name is often used to refer to two different programs. When applying for benefits as a disabled person, the applicant has to apply to two separate programs, Social Security Disability (SSDI) and Supplemental Security Income (SSI). To qualify for SSDI, you must work a certain number of years before becoming disabled and a certain amount of those years have to have occurred