Embracing complexity in borderline personality disorder

  •  "So, what's your research about?"

    It is the question doctoral candidates dread. Reducing our research to a consumable soundbite is no mean feat, especially when we are usually working on topics unfamiliar to most outside, and often even within, our fields. It took me a long time to land on my bitesize research description, but I finally landed on saying I am doing Medical Humanities research on Borderline Personality Disorder. It being a relatively new area, I typically have to define Medical Humanities - which is not so bad, I just say it's the study of medicine (including psychiatry) through a historical, literary and philosophical lens. I am then faced with defining Borderline Personality Disorder. BPD is a diagnosis of so many layers, and an experience of such complexity, that describing it succinctly is almost impossible. If I try to capture it in a few simple sentences, all nuance will be lost and I will end up perpetuating the very things my research aims to work against. Perhaps I could just say "according to my medical record, it's me!". I am doing this work as a situated researcher, working from within the experience I am studying. This is why the nuance means so much - I know what the stigma costs.

    Borderline personality disorder is a psychiatric diagnosis, given mostly to women (statistics vary, but the most oft cited is 75% of those diagnosed with BPD are women). It was first defined in those exact terms in the DSM III (1980), but has existed in some form (borderline type, borderline states, earlier diagnoses like pseudoneurotic schizophrenia and moral insanity) since the mid 19th century. Throughout the writings on borderline experience, it is characterised by instability (of selves and identities, emotions and affects, choices and behaviours) and what is termed "difficult therapeutic reactions". In other words, borderline patients are seen as difficult patients. They do not behave themselves.

    If we look at the BPD criteria in a little more detail, it's not surprising that the neoliberal medical establishment would pathologise something that so consistently deviates from its vision of "wellness". The traits of BPD threaten the foundational ideals on which psychiatry is built. BPD traits include fear of abandonment and a tendency to intense relationships in which it is unclear "where I end and you begin". This threatens the neoliberal mandate of individualism and independence. It suggests that our lives and experiences are interconnected, that we need each other. Another key trait is an unstable, shifting sense of self. This threatens the Cartesian ideal, the idea that we are all fixed, self-contained, autonomous selves, possessing unlimited agency. Another trait, "inappropriate anger" brings attention to the power dynamics inherent in the therapeutic relationship. The clinician decides what is deemed worthy of anger - as well as what is a normative sense of self, a normal level of relationship intensity etc - and the patient must accept this assessment. If they do not accept it, they are deemed a "difficult patient". The logic is circular.

    There is a huge stigma associated with borderline personality disorder. Several studies have shown that the diagnosis affects how patients are treated in clinical settings. Psychiatric nurses in a 2006 Canadian study showed less sympathy to hypothetical patients with this label than to patients who exhibit the exact same symptoms without the name "BPD". (Aviram, Brodsky and Stanley) Other studies found that mental health professionals tended to view borderline patients as “merely a label for someone who is ‘bad’, not ‘mad’”, or as having "flaws in their nature" rather than a mental illness deserving of empathy. (Markham and Trower, 2003; Castillo, 2000) In the media and in online discourse too, BPD is associated with manipulation, attention-seeking and the idea of the "toxic person".

    This is the landscape that I, as a borderline researcher, find myself in. There has been other work that aims to counteract the stigma and contest the diagnostic category itself. Feminist scholars have written extensively on the ways that the borderline diagnosis can be seen as highly gendered. Some use discourse analysis to deconstruct the language used to describe borderline experience, revealing how feminine-coded much of it is. (Janet Wirth-Cauchon) Others apply a social psychoanalytic lens to argue that BPD is a direct result of female socialisation and a psychological consequence of patriarchy. (Dana Becker) BPD has been linked to early trauma and abuse, and activists have been critical of the medicalisation of what they see as a normal, non-pathological response to these difficult experiences. (Dr Lucy Johnstone, the Drop the Disorder campaign) A more recent area of study is beginning to suggest a link between the low rate of autism diagnosis is women and the high rate of BPD diagnosis, which raises the question of whether girls are being diagnosed as borderline when they are in fact autistic. A recent study found that some traits relating to social difficulties, empathy and systemising may be shared between the two groups. (Dudas et al, 2017)

    All of these critiques of BPD as a diagnosis are valid and important, yet they are not really what my research is about. When asked about my research, I get so caught up explaining these foundational issues of gender, power and stigma, that there is no time left to talk about the actual focus of my work! I am attempting what disability researcher Margaret Price calls "counter-diagnosis". Counter-diagnosis takes a psychiatric diagnosis to be a kind of narrative, and attempts to make a counter-narrative or anti-narrative in response. It resists or "queers" the binary of accepting/rejecting a diagnostic label, instead using the very experience which has been pathologised to “subvert the diagnostic urge to 'explain' a disabled mind”. My research aims to be counter-diagnostic, to look beyond the label and the causes/reasons for BPD, because the lived reality of being borderline is interesting, valuable and potentially radical in and of itself. Drawing on ideas from Philosophy of Psychiatry and Phenomenology, such as the concept of "existential feelings", allows me to explore what it is like to be borderline, experientially, as a form of neurodivergence.

    I am particularly interested in how the diagnostic criteria and psychoanalytic writings on borderline experience rely heavily on binaries (intellect/affect, psychosis/neurosis, rational/irrational, reality/delusion, subject/object, self/other). Combining New Materialist and Posthumanist ideas with my phenomenological explorations of borderline experience is already beginning to illuminate the latter's unique potential for collapsing these binaries. My textual analyses have led me to become very curious about the space of the mirror, and to use this not as a metaphor but as a methodological principle. The work of physicist-turned-philosopher Karen Barad offers exciting applications of the mirror as a “spacetimemattering”, and experience as diffractive, kaleidoscopic and intra-active. The ultimate aim is to go beyond the counter-diagnostic to the counter-therapeutic, finding affirmative meaning within the non-binary, diffractive kaleidoscope of borderline experience. I am resisting the diagnostic (and academic) urge to explain, instead embracing ambiguity, complexity & the unknown. 

    Works cited

    Aviram, R., Brodsky, B. and Stanley, B. (2006). "Borderline Personality Disorder, Stigma, and Treatment Implications". Harvard Review of Psychiatry, 14(5), pp.249-256.

    Becker, D. (1997) Through the Looking Glass: Women and Borderline Personality Disorder, Westview Press, Oxford: England.

    Dudas, Robert, et al (2017) "The overlap between autistic spectrum conditions and borderline personality disorder". PLOS ONE. 12 (9).

    Castillo, H. (2000) "Temperament or Trauma? Users Views on the Nature and Treatment of Personality Disorder". Mental Health Care, 4(2).

    Markham, D. and Trower, P. (2003) "The effects of the psychiatric label ‘borderline personality disorder’ on nursing staff's perceptions and causal attributions for challenging behaviours". British Journal of Clinical Psychology, 42(3).

    Wirth-Cauchon, J. (2001) Women and Borderline Personality Disorder: Symptoms and Stories. Rutgers University Press.


    [Image - Portrait in a Broken Mirror by Francesca Woodman]