Abstract
This discourse analytic study sits at the intersection of everyday communications with young people in mental health settings and the enduring sociological critique of diagnoses in psychiatry. The diagnosis of borderline personality disorder (BPD) is both contested and stigmatized, in mental health and general health settings. Its legitimacy is further contested within the specialist adolescent mental health setting. In this setting, clinicians face a quandary regarding the application of adult diagnostic criteria to an adolescent population, aged less than 18 years. This article presents an analysis of interviews undertaken with Child and Adolescent Mental Health Services (CAMHS) clinicians in two publicly funded Australian services, about their use of the BPD diagnosis. In contrast with notions of primacy of diagnosis or of transparency in communications, doctors, nurses and allied health clinicians resisted and subverted a diagnosis of BPD in their work with adolescents. We delineate specific social and discursive strategies that clinicians displayed and reflected on, including: team rules which discouraged diagnostic disclosure; the lexical strategy of hedging when using the diagnosis; the prohibition and utility of informal ‘borderline talk’ among clinicians; and reframing the diagnosis with young people. For clinicians, these strategies legitimated their scepticism and enabled them to work with diagnostic uncertainty, in a population identified as vulnerable. For adolescent identities, these strategies served to forestall a BPD trajectory, allowing room for troubled adolescents to move and grow. These findings illuminate how the contest surrounding this diagnosis in principle is expressed in everyday clinical practice.
Koehne, Kristy, Hamilton, Bridget, Sands, Natisha and Humphreys, Cathy 2013, Working around a contested diagnosis : borderline personality disorder in adolescence, Health: an interdisciplinary journal for the social study of health, illness and medicine, vol. 17, no. 1, pp. 37-56, doi: 10.1177/1363459312447253
"This study was motivated initially by curiosity and some frustration regarding the tendency for mental health clinicians in inpatient adolescent mental health services to use BPD as a descriptor in discussions among clinicians, while withholding talk about BPD with their adolescent clients. This observation was based on the experience of the researchers as clinicians in a limited array of teams. However, to us the practice of talk behind the scenes and of non-disclosure with clients seemed entrenched and taken for granted. Our common-sense perspective was to favour the ethical stance that when a diagnosis is made, it should be shared. Still there were simultaneous concerns about the diagnosis, its stigma and its utility."
"The study shows how the category of BPD exists as an object of psychopathology within a complex group of social and power relations."
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