Philosophy, Psychiatry, & Psychology

Philosophy, Psychiatry, & Psychology 10.1 (2003) 29-31

On the Border:
Reflections on the Meaning of Self-Injury in Borderline Personality Disorder

Robert L. Woolfolk

Keywords
borderline personality disorder, values, psychotherapy, diagnosis

IT IS A PLEASURE to comment on Nancy Potter's elegantly written, provocative paper. Professor Potter raises important and intriguing issues that have not only clinical implications for practitioners, but also are of theoretical significance for those who ponder the conceptual status of mental illnesses and their manifestations.

Borderline personality disorder (BPD) is the mental health professional's bête noire. In the diagnostic context, borderline is an adjective that is evocative, albeit imprecise. Persons with BPD tend to the worst of multiple pathological worlds, to fall through the diagnostic cracks, to occupy the boundaries of decorum and safety. Even such intrepid and astute folk as Marsha Linnehan and Otto Kernberg, who have devoted careers to understanding and treating those with BPD, have acknowledged the limited state of current knowledge. Justice Stewart's theory of natural concepts seems to apply to patients to whom we give the label borderline personality disorder: we cannot define the disorder readily, but we know one when we see one. And when we see such a patient it is costly in time and stress and corrosive of one's sense of professional efficacy. So with these patients, any assistance in conceptualizing the problem or in modification of therapeutics is welcome.

Professor Potter's phenomenological formulation of self-injury is cogent and helpful in a number of ways. Self-injurious behavior is, when conventionally interpreted, a prototype for irrationality and affliction. It is also dramatic, graphic, and often repugnant. Professor Potter's analysis brings us face to face with what most of us know but sometimes forget or fail to apply: Psychotherapy is a value-laden endeavor. Early on, both Max Weber and Carl Jung were eloquent on this point and we have been reminded often enough of it in the last four decades (Rieff 1966; Woolfolk 1998; Woolfolk and Murphy, in press). Usually it is the moral values residing in the underlying ideologies of treatment and diagnosis that are brought to our attention. The axiological underpinnings of psychotherapy, however, are aesthetic as well as ethical. Professor Potter successfully argues that, as therapists, we may be in the thrall of a parochial aesthetic that produces [End Page 29] a kind of tunnel vision inimical to therapeutic effectiveness and to the ethical treatment of the human beings who are our patients. She has impeccable advice for therapists on this topic:

Although none of us can step outside of culture altogether, we can evaluate our attitudes, beliefs, and values from a second-order level (Taylor 1989; Frankfurt 1971). Complete objectivity is an unlikely ideal. But clinicians can, and should, think critically about ways in which prevailing norms and values may be influencing their understanding of the world and their ways of being in it. (Potter 2003, 11)

Professor Potter also quite effectively persuades that a comprehensive understanding of disorders that occur mostly in women (e.g., somatization disorder) must effectively comprehend feminist scholarship and the sociocultural realities of gender. The concept of the commodification of the female body has been informative in both the epidemiology and treatment of yet another woman's disorder, anorexia nervosa. And although the linkages of somatic commodification to self-injurious behavior may not appear to be so straightforward, the paper points the way to deeper and possibly richer explanations of phenomena that seem at first glance to be inexplicable.

The introduction of the concept of uptake into clinical contexts is also a valuable contribution. Those of us familiar with the traditions of psychotherapy recognize a concept both familiar and central. Uptake has family resemblance to the empathic attitude so extensively discussed by both Rogers and Kohut. Those with hermeneutic leanings will recognize affinities with Verstehen and the Gadamerian anticipation of completeness (Vorgriff der Vollkommenheit). Any truly humanistic approach to treatment or diagnosis must encompass the lived experience of the patient. This is not to...