Abstract
In 1995, a Swedish pilot study of Dialectical Behaviour Therapy (DBT) was launched to investigate its therapeutic efficacy and cost-effectiveness as treatment for Borderline Personality Disorder (BPD) in suicidal women. In the same year, a sweeping reform of psychiatric care commenced, dramatically reducing the number of beds by the end of the decade. The psychiatry reform was presented as an important factor prompting the need for a community-based treatment for Borderline patients. This article suggests that the introduction of DBT in Sweden, and its relationship to the reform, can only be adequately explained with reference to the wider political shift occurring at the time, whereby the Swedish welfare state and its guiding ethos of egalitarianism were abandoned in favour of a neoliberal ‘choice revolution’. With the new liberalism, hard work and individual responsibility replaced the idea of a Swedish ‘people’s home’, a nationwide community and social support network. This language was reflected in DBT, which sought to teach patients the ‘skills’ necessary ‘to create a life worth living’. In this context, therapy was constituted as a form of ‘work’ that the patient had to undertake to improve. Moreover, DBT rejected the prevailing view of Borderline patients as ‘manipulative’ and ‘aggressive’, suggesting instead that they were ‘helpless’, ‘weak’ and unable to regulate their emotions. This new Borderline persona fit neatly into the new liberal discourse: she could be taught to become a rational and independent person able to cope in a society that valued individual responsibility over social support.
Jansson, Åsa. (2018). Teaching ‘small and helpless’ women how to live: Dialectical Behaviour Therapy in Sweden, ca 1995–2005. History of the Human Sciences. 31. 131-157. 10.1177/0952695118773936.
Key Quotes
"While distress is perceived to result from a combination of environmental triggers and an individual’s particular vulnerability, the focus is solely on teaching the patient strategies to function effectively in the triggering environment."
"Patients perceived their participation in therapy as a form of ‘work’ requiring diligence and commitment, prompting questions about the role and meaning of work as therapy/therapy as work in 21st-century neoliberal society."
"Much of the language of DBT corresponded to the increasingly popular policy language of the period emphasising ‘responsibility’, ‘independence’ and ‘work’. Moreover, within the SKIP study, the typical Borderline patient was constituted as a ‘helpless’, almost childlike woman unable to control her own strong emotions or to cope with life. DBT was framed as a strategy to teach this Borderline patient the skills she needed in order to function in a society that increasingly valued autonomy and independence."
"[...]DBT has been implemented as a targeted treatment for BPD in a number of countries and multiple studies have been carried out. The vast majority of these hail DBT as a great success in treating Borderline patients. This has also been the case in Sweden. However, the trial, assessment, and measured outcome of DBT as a treatment for female Borderline patients cannot be considered independently from the socio-political context in which it occurred, a context that helped define both the problem to be addressed (the psychopathology of BPD) and what constituted a ‘successful’ outcome. The pathology to be treated: weakness, helplessness and lack of agency and control, and the desired result: an independent woman able to function in the post-welfare society without a strong support structure and thus being less of a financial burden on the system, were both intimately tied up with the new liberal project[...]"
"DBT facilitates a transformation of the Borderline persona from a ‘manipulative’ woman to a ‘helpless’ one, that is, from a person ‘acting out’ with agency and autonomy, to one who is re acting to strong emotions over which she has no control. This transformation is particularly striking in light of Kaver and Nilsonne’s nod to ‘feminist psychotherapy’ in their book, suggesting that this offers a way of framing the emotional distress of Borderline patients as an ‘appropriate’ response to oppression rather than as ‘an expression of personal pathology’ (Kaver and Nilsonne, 2002: 31). While Kaver and Nilsonne acknowledge the potential role of patriarchal ‘power structures’ and ‘social values’ in producing the Borderline pathology, they fail to address the question of language as productive – of gendered features and of psychiatric symptoms, but also of the lived experience of both of these. Following Scott (1991), we might suggest that DBT and its language around female suffering offered new ways for Borderline patients to experience themselves as Borderline patients, new ways to make sense of their distress and how to address it. Through qualitative studies of that experience, patients’ perceptions were fed back into the diagnosis (see Hacking, 1995 on ‘looping effects’), further cementing the Borderline persona as a ‘weak’ woman, but one who could learn – through hard work – how to function as an autonomous and stable individual in a society that demanded that she did so. What is important to note in regard to the present story is that the ‘helpless’ woman better fits her contemporary wider sociopolitical narrative. That is, the infantile and dependent woman constituted by DBT was better suited to being transformed by the neoliberal ‘choice revolution’ into a responsible and independent adult than her wild and (by society) uncontrollable sister who was very much in charge of her own actions."
"Therapists are encouraged to use a mix of positive and negative approaches; specifically, they are advised to switch between ‘validation’ and ‘warmth’ on the one hand, and ‘irreverence’ on the other. This is presented as a particularly effective strategy when dealing with patients engaging in self-harm or in ‘therapy- disrupting behaviour’. In one example offered by the authors, a patient admits in session to having cut herself with a razor blade. The appropriate therapist response is given as validating the feeling that led to the cutting: ‘You must have been feeling terrible’ while not accepting cutting as an acceptable coping strategy: ‘you can’t carry on with this behaviour ! Did you not use any of the skills you’ve learnt?’ When the patient explains what led to the cutting, in this case the therapist failing to answer her phone when the patient rang, the authors advise that an ‘irreverent’ response is appropriate: ‘well the world is full of careless people, you can’t go around killing yourself over that!
Nilsonne and Kaver emphasise that while DBT uses both positive and negative validation, it never relies on punishment. At the same time, however, the strategies presented in their manual amount to a carrot and stick approach, where patients are rewarded when behaving appropriately and reprimanded when engaging in inappropriate behaviour, such as self-cutting[...]
In this way, the Borderline patient is taught to respond appropriately and responsibly to difficult life events, as inappropriate reactions will have negative consequences in terms of the patient’s therapeutic experience. Moreover, the terms of the contract ensure that if the patient wants to continue to receive help (therapy) she must adhere to the contract and conduct herself in a manner that is considered responsible in the context of DBT. The process described above is reminiscent of a parent raising an obstinate child. This type of therapeutic relationship has a history as long as psychiatry itself: it can be traced back to the ‘moral treatment’ of the early 19th century, where the fatherly alienist used a mixture of kindness and discipline to coax the ‘lunatic’ back to the world of responsible and rational human beings. Moral treatment also saw patients engaging in various forms of physical and mental activities (such as manual work, sewing, painting, singing, and going to church) designed to occupy their minds (and, in some instances, provide free labour)."
"Thus, in the same way as the 21st-century neoliberal ethos draws upon a Victorian values system, moral treatment has far more in common with the behavioural therapies of the late 20th century, particularly DBT, than it does with the early post-war talking therapies, which can on the contrary be seen as part of the post-war Social Democratic project in Western Europe. Moreover, the occupational aspect of moral treatment can be compared to the 21st-century ‘workfare’ concept referred to above, a programme that encourages ‘labour on the self in order to achieve characteristics said to increase employ- ability’ (Friedli and Stearn, 2015: 40). This is mirrored in DBT’s focus on ‘hard work’ in order to learn the skills necessary to improve one’s own quality of life. DBT, then, draws upon language and values central to turn-of-the-millennium Western society: freedom, choice, independence, and responsibility for one’s own life situation. At the same time, this relationship between DBT and its cultural context is a circular one, in that the former helps reinforce these values by teaching patients to internalise them. This process more- over applies to late-modern psychiatric conceptions of ‘self-harm’ more generally, whereby ‘neoliberalism’s stress on individual actors’ radical freedom to make choices for their own benefit fits well with a model of self-harm that emphasises the individualistic, private feelings of tension, and the self-regulation of these through cutting’ (Millard, 2015: 205)."
Note from PDV!: Many people find DBT highly successful, just as many people find their diagnosis validating, but just as what constitutes an illness is political, so are the approaches taken to treat such an illness. For all that Lineham pushed to reduce power imbalance between clinician and service user, that is not what was taken from her introduction of DBT. Instead, we have paternalistic clinicians wielding access to therapy and denial of treatment as a punishment for misbehaviour, at their discretion to define what constitutes misbehaviour. This is only made worse by the fact that "weak and helpless" has not so much replaced the descriptors of "manipulative and aggressive" so much as added to them, and are willing to view anything as a slight against them or deserving of punishment. Clinicians often simultaneously view people diagnosed with borderline/emotionally unstable personality disorder as both pathetic and childish AND manipulative and all powerful.
Following on from Irum's post, we must ask: just because we can train some people to tolerate incredible distress, to accept the world as it is no matter how heinous, should we?
Should we be training women, primarily women with long histories of abuse, just how to Tolerate and Accept their pain with no other measure to address the injustices and harm that has been done to them? Might this serve to normalise the rampant issues of girls being abused and the persistent misogyny that women face? When the pathology is so centered around a person's behaviour and reactions, when the issue recognised is that a person is unable to regulate their emotions instead of working to address why somebody might be so traumatised, how much is the therapy for the service user and how much is simply just to try and force them to be normal?
DBT, like many therapies, moralises emotional reactions as wrong and measures them by how much they interfere with living normally instead of the suffering caused to a person. It enforces the inherently ableist idea that to depend on others is wrong. It pushes as truth that people are inherently individual and that vulnerability is weakness. For all its talk of change, it reinforces powerlessness by that same emotionally abusive dismissive attitude of "toughen up, the world is cruel and there is nothing you can do about it, you are the one that has to change."
For all that DBT has potentially helpful aspects, when all that is offered to people in distress is a punitive rigid course that locates the issue within a person's responsibility instead of what has happened to them and the system and society that enables it, it cannot empower people to truly live full interdependent social lives or address the true cause of such profound suffering.
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