Mapping the Edges and the In-Between
This philosophical and ethical analysis of BPD challenges reductive assumptions that are commonly held in the clinical practice of this disorder.
Potter, Nancy Nyquist. Mapping the Edges and the In-Between: A Critical Analysis of Borderline Personality Disorder. New York: Oxford University Press, 2009.
Nancy Nyquist Potter’s critical analysis of borderline personality disorder (BPD) is empathetic, thoughtful, and thorough. Her central task in this book “is to press questions of to what extent the symptoms of the classificatory disorder BPD represent pathology, or instead, cultural disapproval or social disvalue” (p. 4). She argues that in order to better understand and treat BPD, we need to address a number of symptoms that warrant closer analysis.
Potter challenges the reader to think beyond the standard diagnostic manual, the DSM-5, and to view the behavior of BPD in the context in which it originally developed. She points out that much of the criteria in the DSM-5 for BPD are feeling-based and therefore do not lend themselves to description and measurement. She is under no illusion that many of the diagnostic criteria for BPD such as anger, self-harm, unstable relationships are socially constructed and they are philosophically messy and complex. She sees BPD as socially situated. The majority of those diagnosed are women (about 75%) and this is neither coincidental nor peripheral to treatment.
People diagnosed with BPD have a reputation of being extremely difficult, impulsive, explosive, and angry people. In the first part of the book, Potter discusses several criterion of BPD on their own: identity disturbance, anger, interpersonal relationships, impulsivity, self-harm, and manipulative behavior. At every point, Potter questions the tendency to pathologize or medicalize these behaviors and argues that doing so often interferes with real understanding and connection with a BPD patient. She introduces a detailed philosophical explanation for each of these “problems” and then delves into the social and cultural contexts including a careful exploration of gender.
In her discussion of identity disturbance, Potter locates the individual within the dialectic of the self and other. She argues that the Western notion of identity creates sharp boundaries between self and other that contribute to feelings of isolation and alienation. This construction of identity is culturally distinct—different cultures have different ways of drawing boundaries between self and external world. Therefore the Western concept of identity as unified and stable is a product of dominant ideology. In addition, gender roles and stereotypes contribute to accentuating the view of the male as “subject” and the female as “other” and when females attempt to assert autonomy, they may be viewed as acting outside behavioral norms. Potter writes:
As a class, girl children and women of all ethnic groups experience subordination, disrespect, invisibility, and other forms of oppression—even in societies that have increasingly offered females more opportunities for development and free choices. It is not surprising that the mixed messages and the thwarted attempts to actualize their goals may create, in some women, feeling of emptiness and contradictory sense of self (p. 28).
Potter also tackles the diagnostic criterion of “inappropriate anger” associated with BPD patients. She argues that we need to explore the concept of anger and determine the difference between pathological and reasonable anger as well as the norms that govern the distinction. Our tendency to frame appropriate anger in terms of reasonableness is problematic because that norm is based on a theory of rationality that is biased and gendered. Contrary to men, women’s anger gets pathologized, mocked, and ignored. Understanding emotions and behaviors requires that we attend to cultural milieu in which it is located. Psychiatry decontextualizes the individual, viewing them as a separate entity without considering the larger sociohistorical causes of personal distress. The judgement of an “excess” such as the criterion of inappropriate anger is located in terms of the appropriate response relative to the context. One reason why it is so unclear on what counts as excess anger in BPD patients is because the DSM-5 treats these criteria as simple facts detached from context when they actually require evaluative judgements.
Potter develops an insightful and novel analysis of self-injurious behavior in BPD patients and what marks off socially acceptable and unacceptable body modification. She asks us to consider the body as a text and self-injury as an act of communication. The only way we are likely to learn the meaning of the act of self-injuring is to “give uptake” to the patient’s experience. The concept of uptake comes from philosopher John Austin who argued that when we use words we are performing actions. To give uptake is to recognize the patient’s meaning-making. It requires that a listener hears the speaker. “We have few if any language conventions,” Potter writes, “that lead us through the discourse about self-injury in a way that preserves the integrity of the communicator” (p. 142). Since clinicians are often at a loss to understand the actions of individuals who self-injure, it is so important that we “try to understand what the world looks like from the communicator’s position” (p. 141). Potter’s emphasis on uptake is about a different kind of listening that asks the listener to suspend his or her usual interpretative framework to some degree. Giving uptake can be understood as a methodology. A proper response by the listener is one that conveys an empathetic attitude toward the communicator and an earnest attempt to understand things from the communicator’s point of view.
To provide a framework for ethical responses to and interactions with patients who self-injure, Potter also draws on the theory of signification. With signification, signs are composed of a signifier (marks on a page or sounds) and a signified (what those marks on a page or sounds mean). The signified is the meaning that is inscribed in a term or utterance. The task of the listener is to determine whether or not something is being communicated and, if so, to interpret it. However, it should not be automatically assumed that the patient who self-injures is trying to say something. Not all self-injury necessarily has to have meaning. It is also true that the sign may not be just one thing—it may contain contradictory meanings. She argues that when we interpret signs written on the body, “we must be skeptics with respect to cultural and linguistic norms” (p. 89). This means remaining open to what an individual may—and may not—be saying when a BPD patient burns or cuts herself. In order to understand what is being said, we need to consider not only the cultural norms that shape meaning and interpretation but also the individual speaker. For example, in the context of an economy and culture where body commodification and objectification proliferates, women become increasingly alienated from their bodies. Hence the need to self-injure may be seen as a need for women to experience their body as real.
Potter closes out the first part of her book with a discussion of manipulative behavior. While manipulativity is not listed as a diagnostic criterion for BPD, it is ubiquitous in the literature when discussing and describing patients. It is often the clinician who equates BPD patients with manipulativity and forewarns others about them. Potter argues that due to the pejorative nature of the term and because it refers to behavior that is thought to require management, the use of the term manipulativity needs to be more precise. The usage and meaning of manipulative in society and in clinical contexts is messy. Clinicians tend to use the term as a catch-all category under which morally wrong ways of interacting are included. However, lumping all of these behaviors together is not therapeutically helpful because it does not allow for differentiation between kinds of behavior that vary among BPD patients. Potter draws on Erving Goffman in suggesting that most people on occasion deceive, are indirect about what they want, disguise their true feelings, and intimidate others yet BPD patients are always characterized as manipulative. She asks:
Why are patients viewed through this lens rather than seen as participants in an acceptable social-role interaction in the context, or engaged in a type of persuasion, or as making a move in a negotiation? How can we distinguish normal manipulative behavior from pathological, especially with the apparent variations between behavior and usage? (p. 106).
She argues that the characterization of BPD patients as manipulative may not necessarily be something objectively real in these individuals but due to stereotypes that circulate about these patients. More context is required.
In her analysis of some of the symptoms that characterize BPD, it is worth noting that Potter does not argue against the existence of pathological behavior altogether. She believes there is such a thing. She continually reiterates the seriousness of maladaptive behaviors in BPD patients and the real harm they can cause. Her concern is the sneaky intersection of the medical and cultural when people behave in ways that go against society norms or disrupt standing power dynamics.
In the second part of the book, Potter proposes a series of ethical responses to BPD that she considers to be crucial virtues. Without these virtues, she argues, clinicians are unlikely to be able to form effective and healthy therapeutic relationships with BPD patients. The first of these virtues is trustworthiness. This “virtue of character” is critical to develop when working with individuals who may have experiences of having their trust shattered. Potter states that a “clinician can show her trustworthiness by engaging in critical self-reflection about the rejecting attitudes, assumptions, norms, and expectations that she may be bringing to the therapeutic encounter, as well as institutional (psychiatric) biases” (p. 130).
The second virtue is giving uptake which Potter describes as the “attempt to genuinely understand the communicant’s point of view” (p. 41). She states that “part of knowing how best to treat a particular BPD patient is coming to an understanding of what their behaviors mean to them, and to do that requires an ethics of communication, a central feature of which is the virtue of giving uptake” (p. 146). If we are to give uptake to BPD patients, we will treat each expression of anger, self-harm, each statement or behavior on its own terms and not assume that it “means” nothing. Giving uptake is a virtue that clinicians need to cultivate if they are to assist BPD patients in flourishing. Giving uptake is a such an important virtue because our participation in dialogue and discursive practices create the conditions for us to be fully flourishing individuals. Alternatively, being barred from participation has the effect of impeding our development. Structural injustices sometimes impede members of minority groups from being recognized. A dominant group may or may not decide to uptake a person’s claims on the basis of their membership to a subordinated group. Such constitutes oppression. Potter doesn’t touch much on power, but I think it is important to consider the power dynamics not only of clinicians and patients, the psychiatric institution and patients, and a male-dominated field and BPD patients (who are mostly women). We can imagine situations where some speech acts might be unspeakable for patients or women in some contexts due to political, cultural, or gendered power(lessness). Although the words can be uttered, the utterances fail to count as the actions they were intended to be because they are not taken up by the dominant power. I love the following quote:
The ability to perform speech acts of certain kinds can be a mark of political power. To put the point crudely: powerful people can generally do more, say more, and have their speech count for more than can the powerless. If you are powerful, there are more things you can do with your words…If you are powerful, you sometimes have the ability to silence the speech of the powerless…But there is another, less dramatic but equally effective, way. Let them speak. Let them say whatever they like to whomever they like, but stop that speech from counting as an action. More precisely, stop it from counting as the action it was intended to be. 1
The third and final virtue is empathy. This is a virtue that is often lacking in the treatment of patients with BPD. Potter argues that a central aspect of a clinician’s feelings of anger and entrapment toward BPD patients is the attribution of choice and responsibility for their behavior. In other words, they see patients as blameworthy. However, according to personality disorder theory, patients with BPD do not have full control over their behavior and moral philosophy holds that people ought not to be blamed for things that are beyond their control. Therefore, BPD patients who are genuinely personality disordered and mentally ill deserve empathy. Clinicians need to cultivate empathy in order to emotionally experience others’ worlds, specifically, the world of particular patients.
Potter is a philosopher and her intended aim is to raise questions, not provide answers. While some of the concepts that Potter employs are difficult and complex, her analysis is clear and navigable. She provides an alternative approach for clinicians to relate to BPD patients which reduces the chance of misdiagnosis and helps those suffering from this disorder. She expects a lot out of clinicians who treat patients with BPD and seems to focus less on the responsibility for patients with BPD to take for the therapeutic relationship. However, I do not see this as problematic considering so much literature has focused negatively on patients as being difficult or to blame for this disorder. Potter argues that our understanding of BPD needs to incorporate the careful dissection of taken-for-granted concepts and “epistemic humility” or the willingness to let patients tell their stories.
- Langton, Rae. “Speech Acts and Unspeakable Acts.” Philosophy and Public Affairs 22, no. 4 (1993): 299 . ↩