Susanna: I didn’t try to kill myself.
Dr. Potts: What were you trying to do?
Susanna: I was trying to make the shit stop.
Girl, Interrupted (1999)
As an anthropologist, I study western psychiatric categories and practices as historically specific technologies of moral (and, often, gendered) personhood. I am also a practicing psychotherapist. Along with other concerns, many of my clients meet the DSM diagnostic criteria for Borderline Personality Disorder (BPD). I have clients who cut themselves with glass, binge and purge, starve themselves into numb oblivion, burn words into their stomachs, have difficulty sustaining interpersonal relationships, dissociate, and regularly feel overwhelmed by strong emotions. The academic and clinical aspects of my work, coming as they do from distinct analytic positions, situate me uniquely in relationship to questions of gender, culture, and mental illness in general, and BPD in particular.
Clinicians generally detest working with borderline patients. These clients can present as unpredictable, needy, hostile, overly dramatic, and emotionally draining. As McGlashan (1993: 241) observes: ‘Officially, ‘borderline’ is a diagnostic label. Unofficially, in clinical parlance, it is synonymous with ‘anathema.’’ Gabbard (1997: 26) elaborates: ‘A significant number of professionals within the industry regard borderline patients with contempt.’ And as one psychiatrist told anthro- pologist Tanya Lurhmann (2000: 113), you look for the ‘meat grinder’ sensation: if you are talking to a patient and it feels like your internal organs are being turned into hamburger meat, she’s probably borderline.
Lester, R. J. (2013). Lessons from the borderline: Anthropology, psychiatry, and the risks of being human. Feminism & Psychology, 23(1), 70–77. https://doi.org/10.1177%2F0959353512467969
Key Points
"My insistence that there is a ‘there’ there in BPD, and that it might disproportionately manifest in women, undoubtedly will raise eyebrows among some feminists. Yet I put it forth as a grounded feminist claim. Viewed from the level of cultural critique, BPD pathologizes and reinscribes ‘feminine’ emotionality and irrationality. Yet viewed from the underside, as experiential realities for clients, the characteristics of BPD can take on entirely different meanings. They indicate enormous resilience, adaptation, creativity, and a struggle to survive environments that have been invalidating, abusive, or erasing. Feminist critiques of BPD, by focusing primarily on the clinical discourses that shape regulatory processes, have tended to miss this vital component. Yet when we consider the characteristics of BPD as survival strategies – brilliant ones – for navigating negative early environments that disproportionately affect women (e.g. early sexual abuse), we are called to reconsider the rejection of BPD as necessarily anti-woman, and may even find within it leverage points for feminist claims."
"It is well-trod ground in the social sciences, and particularly within medical/psychological anthropology, that people enact illness and distress in culturally patterned ways and according to social conventions and expectations. It is similarly widely accepted that diagnosticians generally find what they are looking for and miss what they are not. Over time and across cultures, illness categories and explanatory models vary widely, reflecting prevailing beliefs, values, and anxieties about proper moral persons.
"Such observations have led many theorists to view illness categories, especially psychiatric ones, as products of social discourse with little, if any, stable grounding[...]
And because many psychiatric conditions are entangled with issues of moral personhood, they are especially powerful mechanisms for curtailing forms of being deemed undesirable by majority standards[...]
"In engaging with BPD as a cultural phenomenon, then, it is not enough to identify a self-referential semiotic system whereby people manifest the characteristics of BPD because they are induced to live under the description of the disorder. In addition to assuming a relatively consistent mapping of symptoms and diagnosis (which is rarely the case), such an argument presumes that, just as there are motivations for clinicians to interpret women’s symptoms as BPD, there are motivations for women to adopt BPD-like forms of illness expression and to seek BPD as an explanatory model. Yet the diagnosis of BPD is hardly something to which people aspire."
"I understand BPD somewhat differently than my clinical colleagues who see it as a dysfunction of personality and my academic colleagues who see it as a mechanism of social regulation. In my view, BPD does not reside within the individual person; a person stranded alone on a desert island cannot have BPD. Nor does it reside within diagnostic taxa; if we eliminated BPD from the DSM, people would still struggle with the cluster of issues captured in the diagnosis. Rather, BPD resides – and only resides – in relationship. BPD is a disorder of relationship, not of personality. And it is only a ‘disorder’ because, as I explain below, it extends an entirely adaptive skill set into contexts where those skills are less adaptive and may cause a great deal of difficulty."
"It makes perfect sense that a girl growing up in a context where her physical existence, psychological existence, or both felt constantly threatened might become fearful of being left alone and unprotected. Developing a finely tuned radar for others’ emotional states while also knowing that the person who cares for her one minute might hurt her the next might easily lead to fluctuating attachments and difficulty developing a stable sense of self. Perhaps in an attempt to derive some sense of her material imprint in the world or to manage strong affect that was disallowed or invalidated, she might engage in behaviors associated with either intense pleasure or pain. Paranoid ideation and even dissociation could be entirely adaptive skills in a context where damage was not only possible, but likely. In short, all of the symptoms associated with BPD could be viewed as adaptive responses to an environment that tells a child she is forbidden to exist as her own person and that she will encounter grave consequences should she try.
"What becomes problematic is that, as this girl becomes an adolescent and then an adult, such survival strategies are often misread (for many of the reasons critics of BPD have pointed out) as communicating things quite the opposite of what she intends and a looping effect comes into play. If a person with such strategies happens come into a clinical setting, she is likely to find that her skills not only do not translate; they become her undoing (Aviram et al., 2006). What were once survival skills are now deemed ‘frantic’ or ‘inappropriate’ or ‘manipulative,’ or ‘paranoid.’ When a person is continuously misunderstood by others (especially those, like therapists or doctors, whose job it is to understand her), when her experiences and attempts to connect are continuously viewed as scheming or inauthentic, it is perhaps not surprising that rage and despair and feelings of emptiness become entrenched. And she fares little better in the world of academic critique where her struggles are deconstructed as artifacts of psychiatric discourse. She is caught, yet again, in a paradox of existence where to ‘be’ in any form, from any angle, renders her inauthentic."
"What I find most compelling about my clients with ‘borderline’ symptoms is that they are still struggling to exist despite the deep conviction that they do not deserve to do so. And they are still struggling to connect with others, despite being told again and again that they are manipulative and controlling and difficult. Far from being inauthentic, then, these individuals are reaching out into the world in the most honest, direct, vulnerable ways they possibly can, all the while bracing for the invalidation and hostility that they know is likely to follow. They cannot help but reach for connection, and to hold out faith, however dim, that they will find it. I find this incredibly inspiring; it puts front-and-center the impulse for growth and health that I believe exists in all of us, no matter how encrusted with despair, dysfunction, hopelessness, or defeat."
Note from PDV!: I very much agree with Lester, from all I've read of critiques of BPD there remains a focus on the perspective of the clinician. There is a definite disregard for analysing how society shapes what is expected from us by the people in our lives, including our parents and guardians, and gender roles impact how people are treated by others from the moment their sex is declared. If we must conceive of struggles within the confines of "disorder", and certainly not all believe we should, we must at the very least leave the moral categories that have been entrenched in diagnostic categories behind us. As I often insist, it is not enough to just rename BPD, we must reconceptualise what this symptom cluster means to meet the genuine experiences of those who do relate the narrative. Some attempt has been made with the creation of CPTSD but the criteria remains narrow and very much subject to a clinician deciding whether what you experienced qualifies as a Traumatic Event™, while the borders and limits of personality disorder diagnosis grow with every revision.
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