With Mapping the Edges and the In-between Nancy Potter has produced an incisive and thoughtful analysis of one of the ethically and clinically troubling problems of psychiatry: borderline personality disorder (BPD). Mapping the Edges is a slim volume of just 176 pages, but it is stimulating reading from beginning to end. Potter challenges readers to think beyond the standard diagnostic model, but she does much more than this. Many critiques of psychiatry stop at the level of broad conceptual analysis and do not engage with clinical problems. Potter is under no illusion that problems such as emotional dysregulation, anger, self harm and disrupted relationships are socially constructed, but she follows Hacking in insisting that there is something there, beyond what is socially constructed. It is this something that clinicians must engage with, but not by means of an objectified, unreflexive conceptual framework. Potter insists that our understanding of BPD is informed by careful analysis of taken for granted concepts, and most importantly, by "epistemic humility": the willingness to let patients tell us what is going on. The second aspect of Potter's analysis is ethical. She draws on Aristotle's ethics of virtue to argue that technique is not enough, clinicians must display the necessary ethical comportment to fully engage with patients, and to fully respect their experience and world view.
Mapping the Edges and the In-between is presented in two parts. Each of the first six chapters examines a defining characteristic of BPD. Potter does not limit herself to the criteria of the DSM, but draws on research into clinicians' experience of working with people with the BPD diagnosis to consider what makes BPD in the mind of clinicians. Hence manipulation, while it is not a DSM criterion, is given extensive treatment, as it frequently mentioned in the professional literature and considered to be a hallmark of BPD. The second section of the book explores application of the Potter's framework of virtue ethics to clinical practice. Potter brings to her analysis a unique combination of philosophical and clinical skills drawn from her background as an academic philosopher and a clinical psychologist.
There is too much in this book to cover all Potter's arguments, but I will briefly discuss "giving uptake" as it is a central concept within Potter's thesis. The term comes from philosopher of language John Austin, and Potter has explored it in previous work on BPD. To give uptake is to recognize the patient's meaning-making, not just in general, but in the particular circumstances of each presentation. If we are to give uptake we cannot treat people as members of a class, we must treat them as individuals. In relation to BPD, if we are to give uptake we will treat each expression of anger, and each self injury, each statement or behavior on its own terms and not assume that it "means" something. For example, Potter warns against treating all expressions of anger as stemming from some childhood cause. It might be that there is a more immediate perceived wrong, and if we gloss over that perceived wrong we are not giving uptake. The result is that just as we feel unheard when someone dismisses our concerns by saying we'll "get over it" people feel unheard if a listener does not give uptake. This idea recurs throughout the book as a reminder that despite the culturally conditioned frameworks traditionally used for understanding BPD, as clinicians we need to reach beyond these traditional frameworks and understand what it is about each individual that gives rise to self injury, anger and impulsivity. "Giving uptake" is not simply relying on the norms of communication; nor does it reduce to respect or empathy. Giving uptake is a virtue, and one that clinicians need to cultivate if they are to achieve another of Potter's central aims, that of assisting the patient to flourish.
Also important to Potter's thesis is the idea of BPD as socially situated. Over 75% of people diagnosed with BPD are women, and this is neither coincidental nor peripheral to treatment. However BPD cannot be wished away by political analysis, important as such analysis is to understanding BPD. The manifestations of BPD are real, and sometimes put the person with the diagnosis at real risk, not to mention causing real distress. Identity serves to illustrate the socially situated nature of BPD. Identity is central to the DSM definition of BPD, but proves to be a slippery concept when subject to conceptual analysis. Not only is identity culturally variable, even within a 'Western' philosophical framework the self/other distinction implied by identity is problematic. Ricoeur's "self as another" demonstrates this, and leads to a political understanding of identity, one placed at risk in a consumer society. Clinicians need to understand the social and political nature of concepts like identity while still responding ("giving uptake") to each individual's unique experience.
Mapping the Edges and the in-between is at heart an ethical analysis, one which insists that clinicians cultivate virtues of critical reflectiveness and humility with regard to what patients are saying when they give voice to distress. This is especially important with BPD given its history as a perjorative label, and given clinicians' tendency to see the behaviors of BPD as both willful and pathological. This view of BPD is paradoxical, as we generally excuse behaviors that are genuinely pathological, and blame people for behavior that is the subject of their will. To work our way through this apparent dilemma requires applied ethical reasoning, not merely skilled psychological intervention. Psychiatry is not free from values nor should it be. But the values that are endorsed must be carefully and reasonably chosen, not recycled from unexamined stereotypes of objectionable behavior. Mapping the Edges and the In-between is a fine example of careful philosophical analysis which is valuable not only for those seeking to understand BPD, but for any clinician who seeks a critically informed practice.
© 2010 Tony O'Brien
Tony O'Brien RN, MPhil, Senior Lecturer, Mental Health Nursing, University of Auckland, [email protected]