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DISORDERED BOUNDARIES?
One of the concepts most frequently mentioned in the philosophy and rationale for new PD services is the importance of boundaries. ‘Boundaries’ are usually explained as the importance for clients of the therapist or worker setting limits which are predictable and consistent. The idea originates in psychodynamic therapy, based on Freud and other psychoanalytic theorists. Clearly the notion that workers need to be aware of the vulnerability of clients and take care to not abuse or exploit clients in their relationship is paramount. But this focus on boundaries has other effects not as benign as avoiding exploitation. This model is of an expert therapist, who can interpret and predict a client’s needs. Boundaries usually refer to the timing of sessions and to rules limiting contact between therapist and client outside the session time. Often a picture is painted of a client diagnosed with BPD ‘pushing’ the boundaries of a therapist or ‘resisting’ the therapist’s boundaries, and the usual advice given to therapists is of the danger of ‘giving in’ to the client. Already we can see the links between this approach and the common stereotype of women diagnosed with BPD as ‘manipulative’. Indeed, the ‘symptoms’ of BPD include reference to no boundaries in relationships. It seems that women with this diagnosis are seen as deficient in their ability to have ‘boundaries’ in relationships and so it is the worker’s job to help them by setting boundaries for them.
This seems to be a response to the history of mental health services failing to offer a service that works for people who are often diagnosed as ‘personality disordered’. When clients ask for help outside their allocated appointment times, or complain about the help they have been given, or communicate in other ways that the services offered are not enough, the result has historically been for services to blame the clients for this response and constrain their services even further. The discourse of ‘boundaries’ serves to blame the clients for the service not working. Often appointments are offered at specified times in advance, which will not serve a need for a client in crisis. When clients turn up to such services, because no crisis provision has been arranged, the clients are blamed, rather than a lack of care planning being identified. When clients do not ‘get better’ in a specified timescale, rather than blame the lack of long-term services, the client is blamed for being ‘unable to use a focused intervention’. This then justifies women with
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the diagnosis being blamed when the boundaries set by the services mean that services are not offering enough to help when a woman is distressed. Consequently, the woman herself is labelled as being ‘too needy’ (e.g. see Proctor, 2002b). This message can reinforce how women may see themselves, as being unworthy of care, and can increase distress at times when women are most in crisis.
The standard ‘professional’ model of care can ignore the subjectivity or personhood of the therapist or worker. The danger here is that these ignored needs are projected onto the client and then used to justify the therapist’s own limitations as being ‘boundaries for the good of the client’. For example, a worker with many responsibilities becomes increasingly frustrated with a client who regularly turns up in distress wanting to speak only to this worker. The worker decides the client is ‘overstepping boundaries’ and introduces a rule that the client can only turn up once a week, explaining to the client that these boundaries are for her benefit. The worker does not explain that she is unable to keep up with all her responsibilities and has reached a limit. Instead, the ethics of mutuality lead to more equitable relationships based on mutuality, where each has needs and limitations and these are discussed openly and honestly (see Proctor, 2004: 24–5). This is preferable to relationships based on dominance and submission: the more usual model for relationships in our society (Benjamin, 1988).
A major difficulty in discussions of ‘boundaries’ is the danger of workers constraining themselves to avoid potential abuse, but totally missing the danger of neglect. Taylor (1990) suggests that most women have already experienced too much emotional remoteness and that relating to a real person in a helping relationship is an essential part of empowering women. This is even more likely to be the case when working with women who have histories of abuse and abandonment. A refusal to be authentic and present in relationships can be experienced as abusive, and can result in harm. Heyward (1993: 137) notes:
It was becoming increasingly clear to me that abuse—damage, harm, violence—can result from a professional’s refusal to be authentically present with those who seek help; and that such abuse can be triggered as surely by the drawing of boundaries too tightly as by a failure to draw them at all.
As mental health services are currently struggling with how to respond to recent government legislation suggesting that BPD should not be a diagnosis of exclusion from services, surely the bottom line of any service aims should be to avoid making women’s and girls’ distress worse. We, as service providers,
should not constrain ourselves by arbitrary or theoretical boundaries that restrict our human capacity to respond to people and care. Why should our boundaries be constrained by anything more than our own limitations of comfort within which we can look after ourselves and be able to honestly and openly respond to the needs of women and girls in distress?
DEFENSIVE OR HEALING PRACTICE?
A far better way to deal with the inevitable limits to what services can offer would be for mental health workers to be honest about their own limits and express them as such without trying to pretend that these limits are good for the client. If workers could be more honest about their limitations, then clients’ need for other support and services could be identified and filled elsewhere. With this honest and mutual exchange, there could then be real attempts to fill the gaps in services and try to provide what women say they need.
To take the ethics of mutuality seriously is a big commitment, emotionally and politically. It requires clear commitment to our own self-awareness and a willingness to discuss the ethics of our decisions and ways of being with clients. If we want to take seriously the healing potential in mutuality, this will not be an easy or safe process. It has the potential to transform mental health services and indeed all our relationships. However, we cannot work this way without strong relational networks of support and solidarity.
CONCLUSION
In this chapter, I have taken a critical look at the growing prevalence of labelling women with BPD. BPD was presented as a particularly controversial diagnosis, which is highly stigmatised, with no agreed cause and few associated treatments—in practice, a catch-all label applied to ‘difficult patients’. Many girls who self-injure are likely to end up being diagnosed with BPD, as self- injury is a highly stigmatised form of behaviour, which challenges many of society’s norms and expectations. Women’s and girls’ distress can be understood as a response to our experiences in a society where power is shared unequally between men and women. Referring to a large body of feminist work, BPD is situated in a long history of responses to women’s distress, denying the impact and extent of childhood sexual abuse. The diagnosis of BPD is criticised for focusing attention on the individual woman, rather than on the context of her life.
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Women and girls who have been sexually abused or traumatised must have their needs and experiences taken seriously and feel a sense of control over treatment within services. Women and girls need people who respect the strengths and qualities that have helped them survive. Workers are needed who see women and girls as equals and as the experts on their own lives. Women and girls need to be understood in the context of our lives and relationships. We need mental health services to see sexual abuse as an issue that affects the whole of society, and which needs a political and societal response. Diagnosing women with borderline personality disorder achieves none of this.