Wednesday 20 March 2024

Affective injustice and borderline personality disorder

Borderline personality disorder (BPD) is a contentious and heavily stigmatized diagnosis. This is something one cannot help but become acutely aware of when navigating the healthcare system with a BPD diagnosis. We are stereotyped as attention-seeking, manipulative and intentionally antagonistic. Such stereotypes and beliefs about people with this diagnostic label inevitably influence clinical encounters. Moments after being diagnosed, a well-meaning nurse encouraged me not to disclose my diagnosis if I were ever to seek private psychotherapy. Some therapists, he noted, simply refuse to work with people diagnosed with BPD.

I am particularly concerned with how diagnostic criteria for BPD may interact with negative stereotyping in particularly harmful ways. One of the nine diagnostic criteria (of which five are required) for BPD listed in the DSM-5-TR is display of ‘Inappropriate, intense anger or difficulty controlling anger’. This criterion is notably wide and stated examples range from extreme sarcasm to recurrent physical fights. The openness of the criterion is not in itself a bad thing, it may even be necessary for clinicians to apply it to individual persons with unique and complex ways of being in the world. The danger is that such openness can increase use of stereotyping that can lead to situations wherein our anger is dismissed – from the outset – as inappropriate and pathological.

Initially, this may seem like a case of testimonial injustice – roughly, a form of epistemic injustice wherein someone’s standing as a knower and credible testifier is undermined due to negative prejudices about their identity. For example, the idea that people diagnosed with BPD are purposefully hostile could lead clinicians to make biased assessments of the legitimacy and proportionality of our anger.

The ‘problem’ with anger, however, is that it is not clear that what we are dealing with are claims to knowledge and, consequently, that prejudice-driven dismissals of anger as inappropriate or pathological always involve an epistemic wrong. Imagine a case where negative stereotypes lead clinicians to assume that (nearly) all anger experienced and expressed by someone with a BPD diagnosis is inappropriate and pathological. Even in instances where the anger may indeed be inappropriate because it involves or is based on an incorrect belief, the fact that such anger is met with an assumption of (a pathological kind of) inappropriateness seems wrong. It is not clear to me that this wrong is epistemic.

Mit liv (My life in Danish) by Leif Hakon Olesen, from a collection (Livsbilleder, 1995) of painting and poetry made by service users at the social institution Basen that operated in the Danish town of Aarhus in the 1990s.

Instead, it may be a distinctly affective wrong, a form of affective injustice. Affective injustice has been defined as the phenomenon whereby people are wronged as feeling or affective beings. It may, for example, occur when racialised people’s anti-racist anger is dismissed as counterproductive to constructive debate, in turn, putting them in a normative conflict between their apt emotional responses to racial injustice and desire to better their situation.

It may also occur, I would argue, when the affective experiences of people diagnosed with BPD are viewed through a lens of pathology and negative stereotypes to a degree that makes it incredibly hard (if not impossible) to have our anger be seen as genuine and sometimes appropriate reactions to past trauma, neglect, discrimination and apathy.

Astrid Fly Oredsson is a self-described PhD drop-out with formal training in philosophy and lived experience of navigating various healthcare systems with a BPD diagnosis. 

Her research interests lie in topics such as psychiatric diagnoses, emotional experience and epistemic and affective injustice.

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