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.