Testimonial Injustice And Borderline Personality Disorder

14/02/2017 14:36

Mental health services are supposed to help. But sometimes psychiatric professionals cause damage by denting the credibility of individuals, a legacy which can last a lifetime. This is a particular problem for women who have experienced trauma, and get placed into what many see as the dustbin diagnosis of 'Borderline Personality Disorder'. The relatively new notion of 'Epistemic Injustice' may help us understand why.

Epistemic Injustice, a concept developed by philosopher Miranda Fricker, is when wrong is done to someone in their capacity as a knower. A subtype - Testimonial Injustice - refers to how the levels of credibility we give one another can be inflated or deflated owing to prejudices about groups which swirl in the social atmosphere. These prejudices can be overt and pre-emptive, for example excluding patients from meetings where their care is being discussed, thus cementing the skewed power dynamic between professional and patient. Or they may be more subtle. For example, if a patient discloses a piece of their personal history as potentially significant, a clinician may appear empathic but offer no follow-up question, or send out cues like picking up notes to block further conversation. Some of these responses are to do with the ever increasing lack of time in the NHS for meaningful connection. But most are to do with unconscious negative prejudices about particular groups.

No group in mental health is subject to as much prejudice as those given a diagnosis of 'Emotionally Unstable Personality Disorder' or 'Borderline Personality Disorder' (BPD). 'BPD' is storied as a syndrome characterised by experiences such as fear of abandonment, extreme mood lability, an unstable sense of self, and self-harm. Women - for it is 75% women - with this diagnosis are labelled as 'manipulative' and 'attention seeking'. This kind of language use, which would be seen as pejorative elsewhere, situates professionals as knowing something about the complicated nature of personality disturbance attributed to such women; it boosts membership of the in-group 'professional'. But these hermeneutical claims just do not fit the evidence. 'BPD' is so dubious a category scientifically that it was almost dumped from the latest version of the biggest international diagnostic bible. It clusters women who dissent, who disobey, who resist together, as if these reactions were signs of pathology rather than spirit against the odds.

Yet 'BPD' as a category remains, serving as a kind of shorthand between professionals that there is something difficult about someone, that this particular patient might produce strong feelings like rage or desire in the clinician, that a distance needs to be kept. Staff who like women with this diagnosis are seen as procuring 'splitting' between team members, and are forced themselves to toe the line of being equally distant to show professional competence. A&E staff, reading this label in notes, take suicide attempts less seriously. GP receptionists act with hostility, the prejudice against women with 'BPD' being that they are time-wasting yet again for attention, undeserving somehow. These reactions imply connecting with women with this diagnosis is what Fricker calls an 'ethically bad affective investment'. These deny women the kind of relationships that could help heal. This discursive disenfranchisement kills.

Testimonial Injustice works subtly but powerfully here. Abuse histories are acknowledged on the surface, but the pathologisation of understandable emotional sequelae, and a treatment focus on controlling emotions in the present, rather than foregrounding the testimony of survivors, reinforces the abuser's attacks on survivors' epistemic subjectivity ('noone will believe you', 'it's your fault for seducing me'). Category inclusion undermines the fundamental right to speak and be heard.

These credibility slurs are experienced viscerally by survivors. Many people report, for example, a sudden shift to kindness, understanding and empathy after a change of diagnosis from 'BPD' to 'Bipolar Affective Disorders'. Self-harm and suicide attempts are suddenly reacted to with compassion and care. By contrast, those who cannot get their diagnosis changed feel branded for life.

We must campaign to get rid of the diagnosis of 'BPD'. But we must not simply create a new label - Chronic PTSD - for the same prejudices will slide on to it. To really change the negative stereotypes, we need a new language, a new social understanding of why and how people end up in deep distress, and how contact with psychiatric services can damage.

Fricker offers a pertinent example. In the 1960s, society did not recognise sexual harassment, so the behaviour of harassers was typically tolerated or even excused. As a result, women were victimised because the wider social context did not label such behaviours as sexual harassment. Indeed such women were seen as troublemakers until they had a chance to meet together, to forge a new language that would come to give a discursive platform for other women to speak from.

We need a similar consciousness-raising, language-generating process in mental health. One where professionals step back from imposing understanding, imposing labelling, and wait to be led by frameworks that develop from survivors.

We need, in doing this, to acknowledge the historical wrongs done to survivors in the mental health system, wrongs that continue today. We need to do this in acknowledgment that professionals have often squashed survivor initiatives into a shape services recognise, and further pathologised those who object. We need to do this, urgently, ethically, to redress the silencing of survivors, a testimonial injustice the psychiatric professions have inadvertantly colluded with.

If you would like to share your experiences or opinion, please tweet using the hashtag #TraumaNotPD