Borderline Personality Disorder and the Ethics of Care in an American Eating Disorder Clinic
TW for discussion of eating disorders, self harm, suicide
Abstract
This paper examines the moral work of a controversial psychiatric diagnosis—Borderline Personality Disorder—in an American eating disorder treatment center in the era of managed mental health care. Based on fieldwork at this clinic spanning more than 6 years, I consider how clinicians invoke aspects of Borderline Personality Disorder in everyday conversation, in a practice I call “borderline talk.” I argue that borderline talk emerges in response to being caught between contradictory models of the subject entailed in managed care and psychodynamic discourses. Specifically, borderline talk enables clinicians to endorse a formulation of the subject that, although considered pathological, provides them with a clear path of ethical action in otherwise ethically ambiguous situations. These kinds of everyday ethical negotiations percolate throughout the American health care system and are key mechanisms through which notions of economic expediency become entangled with concepts of the healthy subject. As clinicians struggle out a course of action between competing ethical imperatives, they also struggle out the workability—and failures—of various articulations of the subject within contemporary American cultural ideologies of health and pathology.
Rebecca J. Lester, "Brokering Authenticity: Borderline Personality Disorder and the Ethics of Care in an American Eating Disorder Clinic," Current Anthropology 50, no. 3 (June 2009): 281-302. https://doi.org/10.1086/598782
Key Points
'It seems that, like a black hole, the self-void at the center of BPD is thought to exert a pull on its surroundings and to be detectable precisely by the chaos that swirls around it. Working with borderlines in a clinical setting entails crossing this "event horizon" and plunging into the void. This is thought to be a risky under- taking for a clinician. Jen, a therapist at Cedar Grove, de- scribed the experience as "like encountering those Dementors in Harry Potter. Borderlines suck the life right out of you." In fact, a therapist's own emotional reactions to a client are thought to be an important diagnostic tool for identifying "borderlines." One of Luhrmann's (2000, 113) psychiatrists described it as the "meat grinder" sensation—if you [are] talking to a patient "and it fe[els] like your internal organs [are] turning into hamburger meat," she is probably borderline.'
'What is notable is that the practice I call "borderline talk" involves a specific figuring of the client's authenticity (or lack thereof) in relation to her actions. It is this feature of borderline talk, I suggest, that enables clinicians to develop a sort of com- promise formation about what is "really" going on with a client and therefore to take action they can feel confident is ethical, even when it contradicts their clinical judgment.
"Borderline talk at Cedar Grove is a mode of everyday discourse among clinicians that invokes BPD to shorthand clusters of behavioral and interpersonal concerns. It takes a number of forms. It can be explanatory, accounting for a client's behavior ("She's really borderline. She can't handle that kind of feedback from her peers without going into crisis"). It can be cautionary, as a way of preparing another clinician for an encounter ("Watch out! She's in full borderline mode today!"). It can also become a way for therapists to communicate to each other their personal struggles or even burn out (like the Dementors comment). Other examples of borderline talk include comments like, "That drama really shows the borderline side of her," "I think her borderline part is getting in the way of her recovery," or "Trying to do group therapy with all these borderlines is like herding cats."
'From what I have observed at the clinic, borderline talk is not always clearly tied to symptomotology, or at least not consistently so. While it is certainly not random, borderline talk does seem to cohere around some clients more than others and to assume different intensity and serve different purposes in different circumstances. This would seem to suggest that borderline talk among Cedar Grove clinicians involves a metadiscursive process that goes beyond a simple diagnostic evaluation of a client. In fact, I propose that borderline talk articulates at least as much about the therapeutic process in the clinic itself—and its inherent tensions and contradictions—as it does about any particular client or group of clients. I have become interested in how the rendering of a nonself in BPD articulates core, paradoxical formulations of "authenticity" in the clinic's own program of recovery— through which clients (often unsuccessfully) struggle to manifest convincing emergent selves—and how these paradoxes crystallize broader cultural contradictions about mental illness and valued "selves" enfolded in contemporary American psychiatric discourse.'
'The standard managed care view is very different from Cedar Grove's. In synergy with biomedical psychiatry and cognitive-behavioral approaches (which enable controlled outcomes research and, therefore, lend themselves to cost benefit analyses in ways psychodynamic approaches do not), managed care tends to figure these illnesses as episodic cognitive-behavioral dysfunctions that are essentially resolved once the symptoms abate (Wiseman et al 2001). From this perspective, unlearning an eating disorder rests primarily on interventions targeting the specific behaviors involved (food rituals, caloric restriction, purging). The underlying causes and ongoing functions of an eating disorder are not a focus of concern, and issues such as "voice" or "sense of self are deemed irrelevant. Managed care rests on a rational choice model that presumes people act out of a desire for self preservation. In light of this, the etiology of eating disorders, and the difficulties clients have in relinquishing their behaviors, do not easily compute and are frequently viewed with skepticism and even dismissal by managed care providers. When I asked one care provider about why her company excluded eating disorders, she answered that eating disorders are "self-inflicted illnesses," so they should not be covered by insurance. Another told me that eating disorder clients are "a nightmare" for his company and his supervisors have told him to "get them off [his] caseload as quickly as possible.' [How familiar]
'Given this, clinicians at Cedar Grove must continually strike a balance between contradictory and conflicting imperatives about best ethical practice in treating their clients. From what I have seen, this usually entails a rather simple (if sometimes creative) process of "code switching" between the psychodynamic concepts and discourses used in everyday practice at the clinic and the more formulaic, objectivist discourses recorded in documents reviewed by the MCO, such as treatment plans and progress notes[...] Therapists must become self-consciously adept at switching between these modes of dis- course and representing psychodynamic thinking about the client's progress in rational choice language about how that progress is made visible in observable behavior. To this end, therapists participate in mandatory quarterly trainings on how to write useful progress notes and document effectively, and this code-switching is openly discussed in weekly staff meetings[...] I want to be clear that this is not the same as lying. It is more a question of framing information in way to make it, as Cathy the insurance manager describes it, "more digestible" to the managed care companies (see also Anderson 2000). In this way, therapists learn to broker client behavior in order to receive continued treatment coverage.
'Nevertheless, there is one arena where this code-switching seems exceptionally problematic and where the incommensurability between the psychodynamic model and the man- aged care model of how to understand client behavior is, perhaps, too profound: client noncompliance while in treatment. Noncompliance can describe a range of things, from outright refusal of treatment interventions to other kinds of "acting out" behavior. It is in evaluating noncompliance that I suggest questions of a client's authenticity emerge as central to ethical decision making at the clinic. To what extent is she genuinely invested in her own care? How can we know? These questions turn on how we understand the relationship between a client's outward behavior and her internal commitments.'
'Grounded in a rational choice model of human behavior, the managed care approach assumes that patients will make good faith use of treatments as prescribed in order to maximize health and minimize harm. Accordingly, this model emphasizes a standardization of the provision of care, and services are "managed" according to such assumptions about client participation. This model assumes that individuals can and will freely choose from among an array of options and will maximize their health benefits in the service of self-preservation and development.
'The managed care approach, like the psychodynamic approach, then, is predicated on a particular idea of the modern liberal subject and the centrality of autonomy in healthy (correct) action. The autonomy advanced in the managed care approach is one grounded in the capacity to reason and act in the world, unfettered by maladaptive impulses. In this regard, it elaborates the procedural notion of authenticity by emphasizing the quality and development of competencies as indicative of increasing autonomy. Whether such action reflects the kinds of authentic commitments (in an epistemic sense) of the subject is of little relevance to the exercising of autonomy in this fashion. Rather, authenticity in the managed care model is gauged as the degree of correspondence between a client's behavior and the indicators of health outlined by the MCO, whether or not such behavior reflects the personal values or commitments of the client herself.'
'The care manager maintains that, because Caroline's acute symptoms of bingeing and purging have abated, she is no longer eligible for care. The cessation of symptoms marks the end of the present episode of disease. Whatever difficulties remain, he suggests, are due to an underlying, chronic personality disorder which, in his view, is outside the scope of the MCO's treatment purview, primarily because "you can't treat borderlines" (i,e,, there is little evidence-based research on which to design standardized treatment interventions for this condition). Ignoring for the moment that this is factually untrue (Feigenbaum 2007), what the care manager seems to be communicating is that he recognizes that Caroline is not "well," but neither is she sick enough —or rather, not sick enough in the right way —to warrant further care. Because BPD is seen as a chronic, life-long condition, Caroline can presumably do nothing about it: once a borderline, always a borderline. Given managed care's privileging of the role of rational choice in achieving health, treating someone with BPD for BPD, where the capacity for rational choice is viewed as explicitly absent, indeed makes little sense.
'The Cedar Grove clinicians, coming from a psychodynamic perspective, strenuously disagreed. The cessation in treatment of Caroline's eating disorder symptoms did yet not represent, in their view, an authentic shift in Caroline's subjectivity. If they could keep Caroline authentically engaged in recovery, they argued, she could continue to get better. But withdrawing treatment support prematurely and not treating Caroline for these more chronic, underlying issues, as the managed care company insisted, doomed her to relapse.
'By characterizing Caroline as borderline (and therefore untreatable), the MCO care manager was asserting that the two are not contiguous and that they entail different sorts of processes with different likelihoods of success. Caroline's eating disorder symptoms had improved, bringing her actions more in line with the value of health as self-preservation. From a procedural standpoint, such as that endorsed by the MCO, Caroline had developed new capacities for autonomous action vis-à-vis her eating disorder, and treatment was therefore a success.
'From an epistemic viewpoint, however, such as that held by Cedar Grove, the persistence of Caroline's significant psychological difficulties despite the decrease in eating disorder symptoms indicated precisely the opposite—that treatment was not even complete, let alone a success. In fact, an increase in other symptoms might be expected when the coping mechanism of the eating disorder subsides. Cedar Grove argued that Caroline's eating disorder was contiguous with these other difficulties and objected to the procedural view that behavior consistent with an ideal of health necessarily indicates an endorsement of that ideal. They instead argued that, while healthy behaviors are important, they should not be taken to indicate a fundamental shift in a client's ability to embrace self-preservation but must instead be viewed with caution and within a more long-term understanding of the recovery process as difficult and often full of setbacks[...]
'What happened next seems puzzling at first glance. While still vehemently opposing the insurance company's position, over the next several days (as the insurance appeals were playing out), I noticed that in everyday conversation the staff at Cedar Grove began talking about Caroline in ways they had not done before. In fact, it seemed that clinical discussions about her symptoms involved a sort of doubling. When Caroline's bingeing and purging increased after the insurance denial, these behaviors were viewed (as before) as evidence of an ongoing, raging eating disorder. But at the same time, they were increasingly discussed with an edge of suspicion, as part of a manipulative strategy on Caroline's part to circumvent the insurance decision by appearing "sick enough" to warrant continued care. One might wonder (as I did) why Caroline would have to try to look "sick enough" if, as the treatment team agreed, she was nowhere near ready for dis- charge. When I asked about this, Kelly, Caroline's therapist, explained that the problem was that Caroline "needed to feel attached and dependent on us" and, as a result, was unable to accept the insurance decision without becoming unhinged. This, in Kelly's estimation, was what made Caroline's symptoms more about her personality issues (e.g., BPD) than about her bulimia per se. As Caroline's symptoms increased, so did the borderline talk among the clinicians. When Caroline returned late from a pass because she had been out purging, or when she told staff she was feeling suicidal, I began to hear comments in the clinical area like, "Now you're really seeing that borderline part of her" and "That's her borderline side coming out."
'Why would these clinicians appropriate in such an apparently uncritical way the very language deployed by the view the opposed? I want to be clear that I am not arguing that the insurance company exerted some sort of hegemonic influence over clinicians' opinions of Caroline's illness. I actually do not think the clinicians' assessments of Caroline's symptoms changed. What did change, I think, is the degree of clarity the team had about what constituted, for them, ethical treatment for this client, and this is where borderline talk emerged as important. Clearly, Caroline was on a self-destructive rampage. Clearly, she needed further treatment. And clearly, her insurance company would not pay for it. Caroline and her family did not have the resources to pay out of pocket, so she had no other options. From what I saw, the borderline talk in Caroline's case—and in several others I have followed over the past 6 years—became a way for clinicians to work through the ethical imperatives of care in a no-win situation.
'Specifically, borderline talk engages the conflicts between procedural and epistemic authenticity in a singular, if disturbing, way—by rendering epistemic authenticity itself impossible[...]
'If[...] Caroline's behavior is construed as manipulative in large part precisely because she is a manipulator, then it becomes difficult for the clinical team to ever perceive her as acting authentically, regardless of her motivations. In a context where authenticity (procedural, epistemic, or both) is understood as foundational to autonomy and psychological health, this rendering of Caroline as incapable of epistemic authenticity—because she has no authentic self from which to act—configures her as largely outside the purview of reasonable clinical intervention. It therefore upholds an evaluation of her treatment based on her outward actions alone. Under such circumstances, it becomes not only acceptable but ethical to discharge her from treatment until and unless she is prepared to invest in her own care, with the burden for demonstrating this readiness resting squarely with her.'
Note from PDV!: If you have the time and the energy to read the full article I highly suggest it. It includes comments from others which are also uniquely insightful, to which Lester discusses. As one commenter noted, it is not that clinicians do this because they are bad people, it because they are human.
Also in her reply she notes:
'I think the characteristics associated with BPD (e.g., fears of abandonment, chronic feelings of emptiness, impulsivity and reactivity) are very real, and they tend to hang together in patterns much as described in the DSM. As a descriptive heuristic, then, I believe BPD does correspond with something "out there." However, in my experience, and as supported in the literature, what is diagnosed as BPD is often part of a complex adaptation to persistent chaotic or traumatic circumstances. This is not captured in the diagnostic criteria, which are silent on the kinds of systemic dysfunctions that can lead to dysregulated emotional and behavioral patterns. Instead, responsibility is located solely in the client's disordered personality; a personality that can never really be repaired. Because of this, the diagnosis of BPD can ideologically obscure relationships of power (including those of gender, race, and social class) that produce systematic structural violence and trauma.'
--which is possibly the best most succinct criticism of BPD I have encountered and one that I will surely reference.
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