Dialectical behaviour therapy: An increasing evidence base

The cultural change narrative as a core component of therapeutic change

Introduction

Research indicates a similar effect of Mentalization-based treatment (MBT) and Dialectical behavior therapy (DBT) for borderline personality disorder (BPD). However, there is a paucity in studies investigating the change narrative received from and developed in these treatments. The aim of the present study is to investigate similarities and differences in the change narratives provided by MBT and DBT, and how these narratives reflect the rationale, explanations, and procedures of the provided treatment.

Methods

The study is a qualitative analysis of seven interviews conducted by the authors. Three of the participants had received MBT, and four of the participants had received DBT. This study presents an Interpretative Phenomenological Analysis (IPA) of the change narratives received in two specialized treatments for BPD.

Results

The main findings from the IPA were that the change narratives described by the participants reflected the treatment they received. The DBT participants highlighted explicit learning of tools and techniques, with predictable and safe therapists. In contrast, the MBT participants emphasized a long-lasting process of exploring to create procedural learning with therapists who followed their lead.

Discussion

The participants' stories of change shed light on how a change narrative was developed, and therefore how the rationale, explanations and procedures were conveyed differently by MBT and DBT.

Suicide risk among individuals at Ultra-High Risk (UHR) of psychosis in a developing North African country: A 12-month naturalistic prospective cohort study from the TRIP project

BACKGROUND

The limited studies that focused on suicidality in individuals at Ultra-High Risk (UHR) of psychosis were predominantly cross-sectional, emerging from Western countries. We aimed to examine suicide risk among Tunisian UHR and First Episode Psychosis (FEP) patients at baseline, and to evaluate the evolution and correlates of suicidal ideation over a 12-month period in the UHR group exclusively.

METHODS

35 UHR (aged 22.8 ± 4.0 years, 45.7% male) and 33 FEP (aged 27.3 ± 4.8 years, 63.6% male) participants were included. The Comprehensive Assessment of at Risk Mental States, the Positive and Negative Syndrome Scale (PANSS), The Rosenberg Self-Esteem Scale, and The Multidimensional Scale of Perceived Social Support were used.

RESULTS

No significant differences were found between the UHR and the FEP groups with regard to levels of suicidal ideation at baseline. Suicidal ideation scores showed a significant decrease over time in UHR participants (p=.014; η2=0.242). An increase in total PANSS scores at 1 year (Beta=0.03; p=.048; 95%CI 0.001, 0.060; η2=0.182) significantly increased suicidal ideation scores at 1 year in the UHR group.

CONCLUSION

Our findings contribute to the limited body of evidence on this topic by providing new prospective data from a population, country and region that has never been researched previously.

Community Outpatient Psychotherapy Engagement Service for Self-harm (COPESS): a feasibility trial protocol

Background

People who self-harm are at high risk for future suicide and often suffer considerable emotional distress. Depression is common among people who self-harm and may be an underlying driver of self-harm behaviour. Self-harm is often repeated, and risk of repetition is highest immediately after an act of self-harm. Readily accessible brief talking therapies show promise in helping people who self-harm, but further evaluation of these approaches is needed. A brief talking therapy intervention for depression and self-harm has been designed for use in a community setting. This mixed methods feasibility study with repeated measures will examine the feasibility and acceptability of the Community Outpatient Psychological Engagement Service for Self-Harm (COPESS) for people with self-harm and depression in the community, compared to routine care.

Methods

Sixty participants with a history of self-harm within the last six months, who are also currently depressed, will be recruited to take part in a feasibility single-blind randomised controlled trial (RCT). Participants will be randomised 1:1 to receive COPESS plus treatment as usual (TAU) or TAU alone. Recruitment will be via General Practitioners (GP) and self-referral. Assessment of feasibility and acceptability will be assessed via quantitative and qualitative methods including measures of recruitment and retention to the feasibility trial, participants’ experience of therapy, completion/completeness of outcome measures at relevant time-points and completion of a service use questionnaire.

Discussion

The results will indicate whether it is feasible to conduct a definitive full trial to determine whether COPESS is a clinically and cost effective intervention for people who self-harm in the community. Qualitative and quantitative data will in addition help identify potential strengths and/or challenges of implementing brief community-based interventions for people who self-harm.

Trial registration

NCT04191122 registered 9th December 2019.

Experiences of dialectical behaviour therapy in a community setting for individuals with intellectual disabilities

Background There is growing interest in the application of dialectical behaviour therapy (DBT) for individuals with intellectual disability (ID) and recent qualitative studies have explored their experiences of DBT in inpatient and forensic settings. This article aimed to explore experiences of DBT in a community setting for people with ID. Method Eleven individuals recruited from two NHS Trusts were interviewed about their experiences of DBT. Interview data was analysed using interpretative phenomenological analysis (IPA). Results Four superordinate themes and eight subordinate themes emerged from the data. The first superordinate theme 'experience of power' captured participants experience of power within DBT. The second theme 'differences in therapy contexts' highlighted how participants had made sense of different therapeutic contexts. The third theme 'the experience of a positive therapeutic relationship' focused on the qualities and attitudes of the therapist. The fourth theme 'a new way of being' described the impact DBT had on participants' everyday lives and the shift in their sense of self. Discussion This study provides insight into the lived experiences of people with ID receiving DBT. Therapeutic processes including the interplay between factors unique to DBT and features common across therapies are discussed.

Mechanisms and moderators in mindfulness- and acceptance-based treatments for binge eating spectrum disorders: A systematic review

OBJECTIVE

Increasing evidence suggests that mindfulness- and acceptance-based psychotherapies (MABTs) for bulimia nervosa (BN) and binge eating disorder (BED) may be efficacious; however, little is known about their active treatment components or for whom they may be most effective.

METHODS

We systematically identified clinical trials testing MABTs for BN or BED through PsychINFO and Google Scholar. Publications were categorized according to analyses of mechanisms of action and moderators of treatment outcome.

RESULTS

Thirty-nine publications met inclusion criteria. Twenty-seven included analyses of therapeutic mechanisms, and five examined moderators of treatment outcome. Changes were largely consistent with hypothesized mechanisms of MABTs, but substandard mediation analyses, inconsistent measurement tools, and infrequent use of mid-treatment assessment points limited our ability to make strong inferences.

DISCUSSION

Analyses of mechanisms of action and moderators of outcome in MABTs for BN and BED appear promising, but the use of more sophisticated statistical analyses and adequate replication is necessary.

Ayahuasca improves emotion dysregulation in a community sample and in individuals with borderline-like traits

BACKGROUND

Research suggests that mindfulness-based interventions may improve mindfulness-related capacities (e.g., decentering, non-judging, and non-reacting) and emotion regulation. Previously, our group reported that ayahuasca could be a potential analogue of mindfulness practice. The main aim of the current study was to examine the effects of ayahuasca on emotional regulation and mindfulness-related capacities. Secondarily, we sought to explore the effects of ayahuasca on individuals with borderline personality disorder (BPD) traits.

METHOD

This is an observational study of 45 volunteers who participated in an ayahuasca session. The volunteers completed various self-report instruments designed to measure emotional dysregulation (Difficulties in Emotion Regulation Scale (DERS)) and mindfulness traits (Five Facet Mindfulness Questionnaire (FFMQ)-Short Form and Experiences Questionnaire (EQ)) prior to and 24 h after the ayahuasca session. The volunteers were divided into two subgroups based on their score on the McLean Screening Instrument for BPD (MSI-BPD). Twelve participants were grouped into the BPD-like traits subgroup while the rest of them were included in the non-BPD-like subgroup. We performed within-subjects and between-group analyses.

RESULTS

Overall, the participants showed significant improvements on the FFMQ subscales observing, acting with awareness, non-judging, and non-reacting and also significantly improved on decentering (EQ scale) and on the DERS subscales emotional non-acceptance, emotional interference, and lack of control. The BPD-like subgroup also showed significant improvements on the DERS subscales emotional interference and lack of control but not in mindfulness capacities.

CONCLUSIONS

These findings suggest a potential therapeutic effect for ayahuasca in emotion regulation and mindfulness capacities (including decentering, acceptance, awareness, and sensitivity to meditation practice). Based on these results, we believe that ayahuasca therapy could be of value in clinical populations, such as individuals with BPD, affected by emotion dysregulation.

Implementation of Dialectical Behavior Therapy in Residential Treatment Programs: A Process Evaluation Model for a Community-Based Agency

Dialectical behavior therapy (DBT) can be challenging to implement in community-based settings. Little guidance is available on models to evaluate the effectiveness or sustainability of training and implementation efforts. Residential programs have much to gain from introduction of evidence-based practices, but present their own challenges in implementation. This paper presents a low-cost process evaluation model to assess DBT training piloted in residential programs. The model targets staff and organizational factors associated with successful implementation of evidence-based practices and matches data collection to the four stages of the DBT training model. The strengths and limitations of the evaluation model are discussed.

Process and impact of dialectical behaviour therapy: A systematic review of perceptions of clients with a diagnosis of borderline personality disorder

PURPOSE

To identify, appraise, and synthesize findings from qualitative studies of individuals diagnosed with borderline personality disorder who have experienced dialectical behaviour therapy, to gain further understanding of their perceptions of the process and impact of therapy.

METHODS

We conducted a comprehensive systematic search of the literature from several online databases, and appraised them using an adapted version of the Critical Appraisal Skills Programme tool. A meta-ethnographic approach was used to synthesize the data.

RESULTS

Seven studies met the criteria to be included and their quality subsequently appraised. Four main themes were identified through the synthesis process: life before DBT; the relationships that support change; developing self-efficacy; and a shift in perspectives.

CONCLUSIONS

The findings of the synthesis highlight the importance of a number of key factors in the process of DBT, and the impact that the therapy has both on day-to-day life and on individuals' identity.

PRACTITIONER POINTS

Existing outcome measures may not capture the complexity and magnitude of impact of DBT on individuals with BPD. Exploring first-hand accounts of individuals undertaking DBT can offer unique insight into the processes of therapy.

Developing an emotional coping skills workbook for inpatient psychiatric settings: a focus group investigation

BACKGROUND

Evidence suggests an unmet need for provision of psychological interventions in inpatient psychiatric settings. However, inpatient wards can present a challenging environment in which to implement interventions. The authors developed the Emotional Coping Skills workbook, a psychosocial intervention designed to overcome these challenges and provide inpatients with an opportunity for psychologically-informed therapeutic engagement. The workbook includes information and exercises to empower inpatients to understand their emotions and learn to cope with their distress.

METHODS

A qualitative study using thematic analysis was undertaken in two UK inpatient psychiatric hospitals to explore staff's views about whether and how the workbook could be implemented, and on barriers to its use. Thirty-five nursing and occupational therapy staff members participated in four focus groups, and a further two psychologists in semi-structured interviews.

RESULTS

Staff identified key barriers to successful implementation of the workbook. These were firstly, the difficulty in finding time and space for therapeutic work in the stressful ward environment. Secondly, staff identified a culture of emotional neglect whereby neither staff nor inpatients felt able to talk about emotions, and patients' physical needs and medication were prioritised. Thirdly, staff discussed how psychotic symptoms and emotional distress could limit patients' ability to engage with the workbook material. Staff suggested ways in which the feasibility of using the workbook could be enhanced. Firstly, they discussed the importance of encouraging staff to value psychological approaches and to view the workbook as a resource to help them manage their existing tasks. Secondly, they emphasised the value of staff drawing on their expertise to deliver the workbook flexibly in different formats and settings, depending on each patient's particular presentation. Thirdly, they advocated empowering staff to decide the timing of intervention delivery in the context of each inpatient's fluctuations in distress and progress towards recovery.

CONCLUSIONS

The study has highlighted key principles for flexible and well-integrated intervention delivery; these principles will be helpful for enhancing the feasibility of any nurse-delivered psychological intervention in inpatient settings.

Mechanisms of change in dialectical behaviour therapy and cognitive behaviour therapy for borderline personality disorder: a critical review of the literature

Background: Little is known about the "active ingredients" of psychological therapy for Borderline Personality Disorder (BPD) despite a growing evidence base documenting its clinical effectiveness. This information can be used by clinicians to inform service planning and care pathways.Aims: The aim of this study was to review published empirical research investigating the potential mechanisms underlying therapeutic change in Dialectical Behaviour Therapy (DBT) and Cognitive Behaviour Therapy (CBT) for BPD.Method: A thorough search of the PsychInfo, CINAHL Plus, PubMed, MEDLINE and EMBASE databases revealed research into potential mechanisms of change.Results: A total of 52 abstracts were reviewed. After a full text screen of the most relevant studies, 14 met inclusion criteria. Twelve examined DBT and two CBT. Mechanisms of change identified broadly fell into three categories: emotion regulation/self-control, skills use and therapeutic alliance/investment in treatment. Outcomes measured included general mental health diagnoses (e.g. anxiety, depression) and BPD-specific symptoms (e.g. self-harm/suicidality, impulsivity, substance misuse, anger).Conclusion: Further empirically robust research is required to test hypotheses about the influence of the proposed mechanisms on therapeutic change in psychological therapies for BPD.

Borderline Personality Disorder Psychological Treatment: An Integrative Review

Borderline personality disorder (BPD) is a complex and at times debilitating mental disorder, treatment of which has eluded effective pharmacotherapy (Gunderson, 2007). Although once considered untreatable, psychodynamic therapy and cognitive therapy (two types of psychological therapies) have provided hope for better lives for patients with this diagnosis (Gunderson). The author performed an integrative review of the literature pertaining to the present role of evidence-based practice (EBP) using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) definition of BPD to identify symptoms of the disorder. Thirty-eight peer reviewed articles, mostly quasi-experimental, three meta-analyses, two books, and two national psychiatric guideline websites were reviewed. BPD treatment may be successful with a variety of psychological therapies. Application of empirical studies is only part of BPD treatment considerations. Heterogeneous symptom presentation requires much professional interpersonal interaction and the literature is scant on inductive research for BPD. This review is limited to psychological aspects of BPD treatment.

Effectiveness of online mindfulness-based interventions in improving mental health: A review and meta-analysis of randomised controlled trials

Mindfulness-based interventions (MBIs) are increasingly being delivered through the Internet. Whereas numerous meta-analyses have investigated the effectiveness of face-to-face MBIs in the context of mental health and well-being, thus far a quantitative synthesis of the effectiveness of online MBIs is lacking. The aim of this meta-analysis was to estimate the overall effects of online MBIs on mental health. Fifteen randomised controlled trials were included in this study. A random effects model was used to compute pre-post between-group effect sizes, and the study quality of each of the included trials was rated. Results showed that online MBIs have a small but significant beneficial impact on depression (g=0.29), anxiety (g=0.22), well-being (g=0.23) and mindfulness (g=0.32). The largest effect was found for stress, with a moderate effect size (g=0.51). For stress and mindfulness, exploratory subgroup analyses demonstrated significantly higher effect sizes for guided online MBIs than for unguided online MBIs. In addition, meta-regression analysis showed that effect sizes for stress were significantly moderated by the number of intervention sessions. Effect sizes, however, were not significantly related to study quality. The findings indicate that online MBIs have potential to contribute to improving mental health outcomes, particularly stress. Limitations, directions for future research and practical implications are discussed.

A multi-site controlled trial of the R&R2MHP cognitive skills program for mentally disordered female offenders

This study aimed to evaluate the acceptability and efficacy of delivering the Reasoning and Rehabilitation Mental Health Program (R&R2MHP) to female mentally disordered offenders detained in medium and low secure hospital settings. Group treatment participants (N = 18) and control participants receiving treatment as usual (N = 20) completed self-report measures pre- and post-group. An informant measure of ward behavior was also completed by staff. Violent attitudes and locus of control were assessed at 3-month follow-up. Program completion was excellent (89%). A conservative intention-to-treat analysis found significant treatment effects post-group for positive problem-solving orientation, rational problem-solving style, and locus of control (medium-large effect), but no treatment effect for violent attitudes, anger, and ward behavior. At follow-up, a large treatment effect was found for locus of control. Ad hoc per protocol analyses found a large treatment effect for ward behavior. The findings provide preliminary support for the feasibility and utility of delivering R&R2MHP to females in secure psychiatric settings.

Are people at risk of psychosis also at risk of suicide and self-harm? A systematic review and meta-analysis

BACKGROUND

Suicide and self-harm are prevalent in individuals diagnosed with psychotic disorders. However, less is known about the level of self-injurious thinking and behaviour in those individuals deemed to be at ultra-high risk (UHR) of developing psychosis, despite growing clinical interest in this population. This review provides a synthesis of the extant literature concerning the prevalence of self-harm and suicidality in the UHR population, and the predictors and correlates associated with these events.

METHOD

A search of electronic databases was undertaken by two independent reviewers. A meta-analysis of prevalence was undertaken for self-harm, suicidal ideation and behaviour. A narrative review was also undertaken of analyses examining predictors and correlates of self-harm and suicidality.

RESULTS

Twenty-one eligible studies were identified. The meta-analyses suggested a high prevalence of recent suicidal ideation (66%), lifetime self-harm (49%) and lifetime suicide attempts (18%). Co-morbid psychiatric problems, mood variability and a family history of psychiatric problems were among the factors associated with self-harm and suicide risk.

CONCLUSIONS

Results suggest that self-harm and suicidality are highly prevalent in the UHR population, with rates similar to those observed in samples with diagnosed psychotic disorders. Appropriate monitoring and managing of suicide risk will be important for services working with the UHR population. Further research in this area is urgently needed considering the high rates identified.

Learning through cognitive milieu therapy among inpatients with dual diagnosis: a qualitative study of interdisciplinary collaboration

The main aim of this study was to explore the experiences of interdisciplinary collaboration among staff members, applying cognitive milieu therapy for inpatients with dual diagnosis. The study is based on 33 individual, qualitative interviews. The interdisciplinary approach helped the staff to agree on common aims for the treatment of each patient. The cognitive method was useful and provided the staff with suitable tools in their work with the patients. The staff succeeded in developing a good learning climate, where they cooperated on equal terms with the patients. Collaborative team learning and external supervision facilitated personal learning processes.

Effectiveness and cost-effectiveness of dialectical behaviour therapy for self-harming patients with personality disorder: a pragmatic randomised controlled trial

BACKGROUND

A primary goal of dialectical behaviour therapy (DBT) is to reduce self-harm, but findings from empirical studies are inconclusive. The aim of this study was to assess the effectiveness and cost-effectiveness of DBT in reducing self-harm in patients with personality disorder.

METHODS

Participants with a personality disorder and at least 5 days of self-harm in the previous year were randomised to receive 12 months of either DBT or treatment as usual (TAU). The primary outcome was the frequency of days with self-harm; secondary outcomes included borderline personality disorder symptoms, general psychiatric symptoms, subjective quality of life, and costs of care.

RESULTS

Forty patients each were randomised to DBT and TAU. In an intention-to-treat analysis, there was a statistically significant treatment by time interaction for self-harm (incidence rate ratio 0.91, 95% CI 0.89-0.92, p < 0.001). For every 2 months spent in DBT, the risk of self-harm decreased by 9% relative to TAU. There was no evidence of differences on any secondary outcomes. The economic analysis revealed a total cost of a mean of 5,685 GBP (6,786 EUR) in DBT compared to a mean of 3,754 GBP (4,481 EUR) in TAU, but the difference was not significant (95% CI -603 to 4,599 GBP). Forty-eight per cent of patients completed DBT. They had a greater reduction in self-harm compared to dropouts (incidence rate ratio 0.78, 95% CI 0.76-0.80, p < 0.001).

CONCLUSIONS

DBT can be effective in reducing self-harm in patients with personality disorder, possibly incurring higher total treatment costs. The effect is stronger in those who complete treatment. Future research should explore how to improve treatment adherence.

Utilization of evidenced based dialectical behavioral therapy in assertive community treatment: examining feasibility and challenges

Assertive Community Treatment (ACT) programs have been treating individuals with chronic and severe mental illness since the 1970s. While ACT programs were developed to address the treatment needs of severely mentally ill persons traditionally suffering from chronic mental illnesses, ACT programs are seeing a growing number of persons with co-morbid personality disorders. The efficacy of traditional ACT programs in treating individuals with co-occurring personality disorders is uncertain, in particular individuals with co-morbid Borderline Personality Disorder (BPD). Dialectical Behavior Therapy (DBT) has been proposed as an effective approach to treating clients with BPD in this setting. The purpose of this paper is to examine the value of DBT for individuals with BPD in ACT programs. The writers discuss the prevalence of Borderline Personality Disorders in ACT populations, briefly review the literature on DBT in ACT, address the feasibility of implementing DBT in an ACT model, examine potential barriers to this implementation, and highlight potential areas for future research.

Dialectical Behavioural Therapy and Borderline Personality Disorder: Effects on Service Utilisation and Self-Reported Symptoms

In a pilot evaluation study, effectiveness of a 20-week dialectical behavioural therapy (DBT) skills training group program was explored for adult clients with borderline personality disorder (BPD;N= 140). Subjective ratings of depression, anxiety and BPD symptomatology were obtained pre and post group therapy. Objective measures of service utilisation levels were obtained for the 6 months prior to group therapy, the duration of therapy, and the 6 months following therapy. Group completers (n= 68) showed reductions in depression, anxiety and BPD symptomatology, as well as in the number of emergency department attendances. Completers with previous high service utilisation had decreases in telephone counselling calls and inpatient days during therapy, and fewer emergency department attendances post therapy. Completers had larger decreases in service utilisation than noncompleters (n= 72). Simultaneous engagement in individual DBT was related to higher group completion than was individual therapy as usual, but it did not impact on level of service utilisation or psychological functioning. This quasi-experimental pilot study suggests that DBT groups may improve psychological functioning and decrease service utilisation for BPD clients, particularly those with high service utilisation. The treatment warrants systematic evaluation.

Service user experience of adapted dialectical behaviour therapy in a community adult mental health setting

BACKGROUND

Dialectical behaviour therapy (DBT), a skill-based cognitive behavioural treatment, is increasingly used in the treatment of borderline personality disorder (BPD).

AIMS

The study examined service users' perspective on the effectiveness of an adapted DBT programme, delivered within a community adult mental health setting.

METHODS

Semi-structured interviews and focus groups were conducted with eight participants with a diagnosis of BPD about their experience of the programme.

RESULTS

Thematic analysis focused on two key themes: evaluation of therapy and treatment impact. Therapy-specific factors and personal challenges emerged as important themes. Treatment impact raised issues relating to a renewed sense of identity and changes in daily life.

CONCLUSIONS

The study describes the positive and negative experiences of service users with BPD attending an adapted DBT programme.

A feasibility study of mindfulness-based cognitive therapy for individuals with borderline personality disorder

OBJECTIVES

Mindfulness-based cognitive therapy (MBCT) was originally developed to prevent relapse in recurrent depression. More recently it has been applied to individuals at high risk of suicide or currently suffering with anxiety and depression. The aim of this study was to consider the feasibility of MBCT for individuals with a diagnosis of borderline personality disorder (BPD).

DESIGN

The design of the study was a repeated measures, quasi-experimental design employing within-subject and between-subject comparisons of a sample of participants with BPD. Based on previous studies and theoretical models of the effect of mindfulness and of cognitive therapy, pre- and post-group measures of mindfulness, depression, anxiety, dissociation, impulsivity, experiential avoidance, and attention were obtained.

METHOD

Participants attended an 8-week adapted MBCT (MBCT-a) group intervention. A total of 22 participants were assessed pre- and post-intervention and were subsequently divided for analysis into two groups: treatment completers (N= 16) and non-completers (number of sessions attended < 4; N= 6).

RESULTS

The study found that MBCT-a is acceptable to individuals with BPD. Using intention to treat analyses, only attentional control improved. However, post hoc analyses of treatment improvers (N= 9) identified changes in mindfulness and somatoform dissociation. A dose-effect analysis suggested a weak improvement in mindfulness, experiential avoidance, state anxiety, and somatoform dissociation.

CONCLUSIONS

This study suggests that further exploration of MBCT for use with individuals with BPD is merited. The study lends tentative support for attentional and avoidance models of the effects of mindfulness.

Marginalization of borderline personality disorder

Individuals with borderline personality disorder (BPD) face considerable difficulties, both in terms of their symptom and functional status, as well as in attempting to obtain professional help. Their exclusion from appropriate mental health care and opportunities for recovery can be examined using the social construct of marginalization. Pervasive attitudes among clinicians, health care administrators, and policy-makers perpetuate the marginalization of BPD within systems of mental health care. Patients with BPD may be regarded as not suffering from a legitimate disorder, comprising a minority of the clinical population, and/or being a chronic drain on health care resources. Lack of suitable mental health services may be rationalized based on these attitudes. Considerable development in the empirical understanding of BPD challenges these stigmatizing attitudes and calls for critical questioning of the marginalized status of patients with BPD.

Brokering authenticity: Borderline personality disorder and the ethics of care in an American eating disorder clinic

This paper examines the moral work of a controversial psychiatric diagnosis--Borderline Personality Disorder--in an American eating disorder treatment center in the era of managed mental health care. Based on fieldwork at this clinic spanning more than 6 years, I consider how clinicians invoke aspects of Borderline Personality Disorder in everyday conversation, in a practice I call "borderline talk." I argue that borderline talk emerges in response to being caught between contradictory models of the subject entailed in managed care and psychodynamic discourses. Specifically, borderline talk enables clinicians to endorse a formulation of the subject that, although considered pathological, provides them with a clear path of ethical action in otherwise ethically ambiguous situations. These kinds of everyday ethical negotiations percolate throughout the American health care system and are key mechanisms through which notions of economic expediency become entangled with concepts of the healthy subject. As clinicians struggle out a course of action between competing ethical imperatives, they also struggle out the workability--and failures--of various articulations of the subject within contemporary American cultural ideologies of health and pathology.