447253
2012
HEA0010.1177/1363459312447253Koehne et al.Health
Article
Working around a contested
diagnosis: Borderline
personality disorder in
adolescence
Health
17(1) 37­–56
© The Author(s) 2012
Reprints and permission:
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DOI: 10.1177/1363459312447253
hea.sagepub.com
Kristy Koehne and Bridget Hamilton
The University of Melbourne, Australia
Natisha Sands
Deakin University, Australia
Cathy Humphreys
The University of Melbourne, Australia
Abstract
This discourse analytic study sits at the intersection of everyday communications with
young people in mental health settings and the enduring sociological critique of diagnoses
in psychiatry. The diagnosis of borderline personality disorder (BPD) is both contested
and stigmatized, in mental health and general health settings. Its legitimacy is further
contested within the specialist adolescent mental health setting. In this setting, clinicians
face a quandary regarding the application of adult diagnostic criteria to an adolescent
population, aged less than 18 years. This article presents an analysis of interviews
undertaken with Child and Adolescent Mental Health Services (CAMHS) clinicians
in two publicly funded Australian services, about their use of the BPD diagnosis. In
contrast with notions of primacy of diagnosis or of transparency in communications,
doctors, nurses and allied health clinicians resisted and subverted a diagnosis of BPD in
their work with adolescents. We delineate specific social and discursive strategies that
clinicians displayed and reflected on, including: team rules which discouraged diagnostic
disclosure; the lexical strategy of hedging when using the diagnosis; the prohibition and
utility of informal ‘borderline talk’ among clinicians; and reframing the diagnosis with
young people. For clinicians, these strategies legitimated their scepticism and enabled
them to work with diagnostic uncertainty, in a population identified as vulnerable. For
Corresponding author:
Bridget Hamilton, The University of Melbourne, Walter Boas Building, Monash Road, Carlton, Victoria,
3101, Australia
Email: [email protected]
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adolescent identities, these strategies served to forestall a BPD trajectory, allowing
room for troubled adolescents to move and grow. These findings illuminate how the
contest surrounding this diagnosis in principle is expressed in everyday clinical practice.
Keywords
adolescent, borderline personality disorder, disclosure, discourse analysis, subjectivity
Introduction
The field of psychiatric diagnosis is a fertile one for sociological critique (Whooley,
2010). Critique is deep and longstanding, challenging the premise for psychiatric nosology overall and questioning the utility of specific diagnoses (Parker et al., 1995). The
diagnosis of borderline personality disorder (BPD) is among the most vexed. In an era
where medical consultations are expected to include frank communication of diagnoses,
psychiatric diagnoses remain stigmatized and communication is often problematic
(Gallagher et al., 2010).
This article is concerned with an analysis of 23 clinicians’ talk at interview about the
diagnosis of BPD in adolescent mental health contexts, and derives from a PhD thesis by
the first author. Through semi-structured interviews with nurses, doctors and allied
health clinicians, we investigated the ways these clinicians understood and made use of
diagnoses, in the everyday settings of publicly funded adolescent mental health services.
In this article, we detail the major set of findings about the ways clinicians understood
and worked with the diagnosis of BPD in adolescence.
This study was motivated initially by curiosity and some frustration regarding the
tendency for mental health clinicians in inpatient adolescent mental health services to
use BPD as a descriptor in discussions among clinicians, while withholding talk about
BPD with their adolescent clients. This observation was based on the experience of the
researchers as clinicians in a limited array of teams. However, to us the practice of talk
behind the scenes and of non-disclosure with clients seemed entrenched and taken-forgranted. Our common-sense perspective was to favour the ethical stance that when a
diagnosis is made, it should be shared. Still there were simultaneous concerns about the
diagnosis, its stigma and its utility.
Research questions that drove this study include:
• Do mental health clinicians share diagnostic information about BPD with their
adolescent clients, and if so how?
• What are the factors that guide clinical practice in the decision to disclose or to
withhold a diagnosis of emerging BPD to adolescents?
While these questions guided the design of clinician interviews, the question at the core
of this article is simply: how do CAMHS clinicians talk about BPD? Questions of ‘how’
direct the focus of analysis towards the structure of language, seeking to examine: ‘How
certain things came to be said or done, and what has enabled and/or constrained what can
be spoken or written in a particular context’ (Cheek, 2004: 1147).
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Background
Personality disorders occupy a precarious diagnostic position, subject to challenge both
broadly as a psychiatric diagnosis and also within psychiatry, consigned to Axis II and so
excluded from categorization as a major mental disorder in the Diagnostic and Statistical
Manual (DSM) (American Psychiatric Association, 1980, 2000).
Psychiatry continues to be troubled by diagnoses that lack reliability, validity, clear
aetiology and the ability to predict treatment responsiveness (Pilgrim, 2001), arguably
enduring a marginal status within the medical profession (Kirk and Kutchins, 1992;
Manning, 2000). By continuing to strive for those diagnostic goals of general medicine,
psychiatry seeks ‘predictive power in a situation where certainty is low’ (Cooksey and
Brown, 1998: 533). Certainty is low for important reasons. For instance, psychiatric
diagnoses rely upon an interpretive approach, heavily depending upon patient communications of symptoms rather than the measurement of somatic changes, or signs (Pilgrim,
2007). Diagnosis based upon interpretation engenders ambiguity, which is at odds with a
firm categorical system. Furthermore, the interpretation of human conduct may be considered analogous to judgement, thus subjecting psychiatric diagnosis to the criticism
that it comprises value judgements made against criteria of normality (Faust and Miner,
1986; Spitzer, 1981).
The BPD diagnosis in particular has been the subject of considerable debate. It has
been touted a ‘hot subfield’ of research, generating more research than all other personality disorder diagnoses combined (Boschen and Warner, 2009: 139). Being diagnosed
with a personality disorder renders one a ‘contested patient’, where medical jurisdiction
is blurred (Pilgrim, 2001: 254). Theorists critique BPD as a construction that pathologizes deviation from a coherent, unified self or rationality (Shaw and Proctor, 2005;
Wirth-Cauchon, 2001). For example, Wirth-Cauchon (2001) argues that psychiatric discourse (i.e. BPD) positions women who cross the borders of ‘normal femininity’ as
other, while neglecting social causes of distress.
Conjecture surrounding the utility of the BPD diagnosis intensifies in an adolescent
population. Diagnostic criteria in the current iterations of the DSM IV-TR are not age
specific (APA, 2000), prompting debate about the appropriateness of applying adult criteria during the fluid developmental period of adolescence (Bleiberg, 1994).
A review of empirical investigations indicates reasonable consensus around the adolescent BPD construct (Chanen et al., 2009; Gunderson, 2009; Miller et al., 2008a; Paris,
2008; Silk, 2008), however it is common for diagnostic advocacy to be paired with caution. For example, longitudinal researchers call for modification of the DSM to specify
that adolescent personality disorder may not persist into adulthood (Cohen et al., 2005;
Silk, 2008), with apprehension raised regarding the heterogenic nature and weak predictive validity of BPD in adolescence (Becker and Grilo, 2006). Or, alongside a push for
early intervention there is concurrent concern for the unknown impact of stigma, the
potential for refusal of health services and for iatrogenic harm resulting from the increased
utilization of personality disorder diagnoses in adolescence (Chanen and McCutcheon,
2008). Despite research on diagnostic idiosyncrasies of validity and predictive ability, the
question of how the diagnosis is used and whether it is disclosed in everyday practice is
not addressed.
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Researchers and ethicists agree in principle that disclosure of diagnosis is a feature of
good practice (Buckman, 1996) and in line with patient expectations (Benbassat et al.,
1998). Yet clinical practice regarding the communication of diagnoses of mental illness
remains ambiguous. A diagnosis of mental illness is likely to be more contentious and
dependent upon professional judgement, thus impacting upon communication to clients
(Gallagher et al., 2010). Research on the disclosure of BPD in adults is scant, but indicates a reluctance to communicate this diagnosis (Hersh, 2008; Lequesne and Hersh,
2004; McDonald-Scott et al., 1992). While the extent of disclosure to an adolescent
population is unknown, it is likely that practice is impacted significantly by the contested
nature of this diagnosis.
Currently, BPD is defined by a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity that begins by early adulthood
and is present in a variety of contexts (APA, 2000). While the DSM permits the use of
the BPD diagnosis in adolescence (if symptoms have been present for 12 months) the
definition remains vague (Miller et al., 2008) and the evidence base for treatment options
is minimal (National Institute for Health and Clinical Excellence (NICE), 2009).
In response to ambiguities, and in light of the clinical need to respond to these young
people, some researchers champion the pathway of making a provisional diagnosis with
adolescent patients. Specialty adolescent mental health services in Australia offer a treatment model to adolescents with sub-syndromal BPD (i.e. meeting three or more of nine
criteria) thus advocating for early identification and treatment (Chanen et al., 2009).
While these clinicians support the frank communication of a BPD diagnosis among clinicians, they remain silent on the issue of disclosure to the adolescent client.
Theoretical tools
We detail here the theoretical framing of this discourse analysis, including the way we
conceptualize texts and practices.
Discourse analysis
The discourse analysis in this research is framed by post-structuralism. Post-structuralism
enables a critical examination of language, and locates power as constituted through
language (Fairclough, 1989; Fox, 1993). This theoretical stance draws from broader
postmodern philosophies which challenge modernist notions of truth, rationality, the
individual and social structure (Fox, 1993). We apply postmodern philosophy to challenge the diagnostic construct of borderline personality disorder and to consider those
subject positions created by this diagnosis (i.e. clinician and adolescent client).
Methods of discourse analysis encompass diverse theoretical influences and
approaches to data. Discourse analysis as applied here relies upon the pivotal work of
Foucault (1972), via his studies of discourse, medicine and governmentality. In particular we take up his commitment to rethink that which is taken for granted, considered
unproblematic or apolitical. In doing so, we consider the conditions (expressed in everyday practice and language) that support what is taken for granted (Gastaldo and Holmes,
1999) in adolescent mental health care, the diagnostic system and the place of BPD in
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both. Our research therefore aims to surface different spaces for manoeuvre and resistance (Parker, 1990).
We use Fairclough to pin down discourse and to structure the discourse analysis. Defining
discourse as the socially determined use of language (Fairclough, 1989), he provides a valuable adjunct to Foucault, through his attention to socio-linguistics (Rudge, 1998). Data were
subsequently analysed at three levels: the text; discursive practice; and social practice. These
levels will be outlined in brief, with influential theorists identified at each level.
Textual analysis
Transcripts generated from individual clinician interviews, field notes and author reflections formed the basis for textual analysis, with interview transcripts constituting the
bulk of discussion in this article. Analysis at this level incorporates an examination of
metaphor, lexical choice and modality; textual features identified as pertinent within
Fairclough’s (1992) critical discourse analysis. Lexical choice for example, refers to the
way in which speakers select descriptive terms to fit with the institutional setting, or their
role within it (Drew and Heritage, 1992). Modality denotes the extent to which a person
commits themselves or conversely distances themselves from a statement (Fairclough,
1992), as delineated in the discussion on ‘Hedges’.
Discursive practice
Analysis of discursive practice is akin to an interpretative, micro-sociological examination
which focuses on one dimension or moment of social practice (Phillips and Jorgensen,
2002). Scrutiny at this level provides an insight into how people create and follow a set of
shared ‘common-sense’ rules in everyday practices (Fairclough, 1992; Phillips and
Jorgensen, 2002). Aspects from the work of Goffman (1959) are drawn upon to examine
the notion of teamwork and clinician subjectivities. We use Goffman’s theatrical sensibility
to illustrate vividly the constructed nature of interactions between clinicians and clients.
Goffman (1959: 104) analysed roles played in a performance across a range of domains
including ‘the team’ which he defined as ‘a set of individuals whose intimate co-operation
is required, if a given projected definition of the situation is to be maintained’. The way in
which BPD is defined by teams provides insight into the minutiae of daily interactions
(Handler, 2009) and points to those localized networks of power operating within institutions (Foucault, 1984).
Analysis of disciplinary roles, practice settings and the shaping of a case is extended
by Barrett’s (1996) examination of the work of a psychiatric team and the diagnosis of
schizophrenia. As in Barrett’s research, our study of disciplinary idiosyncrasies turns the
objectifying gaze of the ‘psy-complex’ back on itself (Parker et al., 1995).
Social practice
Attending to social practice takes the discourse analysis to the macro-sociological level,
where connections between language, power and ideology are surfaced (Fairclough,
1989). At this level, Foucault’s work provides the predominant theoretical guide with his
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ideas taken up using the analogy of a ‘toolbox’ (Humphreys, 1990: 317). The tools used
in this article include: an examination of enunciative modalities and use of semantics in
the medical gaze; and diagnosis and discipline between clinicians.
Foucault’s (1972: 50) theorizing of ‘enunciative modalities’ prompted questions of
the data such as ‘Who is speaking? Who, among the totality of speaking individuals is
accorded the right to use this sort of language? Who is qualified to do so?’ Such inquiry
provided fertile ground for analysis of clinicians’ talk. We asked both ‘Who can speak?’
and ‘From where can they speak?’ (Rose, 1996: 174). We viewed clinicians’ language
use as an exercise of power. As described by Linnet (2004: 11), ‘language is not what it
describes, it is something else. But it can reveal, point at, or evoke, and make us sharply
aware of reality – or it can soften, smooth over, and mislead.’ Previous sociological studies have considered the way clinicians work around those DSM diagnoses which engender ambivalence (Whooley, 2010). In drawing together these three dimensions of
analysis, we pinpoint particular lexical strategies and modes of performance used by
clinicians, as they take up the contested discourse of BPD.
Analysis is also shaped by Foucault’s (1989: xiii) notion of the clinical gaze, occurring when ‘a millennial gaze paused over men’s sufferings’, thus revealing that manifest
and secret space. Clinical perception is made concrete through the use of language and
description. This article examines the gaze in operation between clinicians and adolescents and among clinicians, producing situated subjects. Accordingly, we redirect the
gaze, ‘not at the mad but at the culture, institutions, and language which make madness
matter so much’ (Parker et al., 1995: 14).
Research design
Participants
Clinicians were recruited and interviewed in two public mental health service sites in the
city of Melbourne, Australia. These teams provided specialist services to adolescents
who lived within a defined catchment area and were under 18 years of age. Adolescents
were referred to the specialist mental health services from a variety of sources: family
physicians; schools; hospital emergency departments; family members; government
child protection agencies and so on.
Upon gaining ethical approval, each team was visited to introduce the research and all
clinicians were invited to participate. Fifteen clinicians were interviewed from site one,
comprised of four community teams and a community day programme. Eight clinicians
were interviewed from site two; an adolescent acute inpatient unit in another metropolitan region. Participants came from disciplines including nursing, social work, psychiatry,
occupational therapy, psychology and general medicine.
Ethics
The study was designed and conducted in line with the Australian NHMRC guidelines
for the ethical conduct of research (National Health and Medical Research Council,
2007). Approval to recruit staff and adolescents was granted by the Human Research
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Ethics Committees at the two healthcare institutions. In order to maintain confidentiality,
potentially identifiable words including names, services and occasionally elements of
medical history were replaced in the transcripts with a brief description (i.e. Case manager). Pseudonyms were allocated for each participant.
Analysis of interview data
An individual, semi-structured interview was audio-taped with the permission of each
participant at their place of work. Analysis commenced during initial reading of the interview transcripts, with the first author building a set of theme files. The term ‘theme’ was
applied broadly at this first stage to include objects, subjects and discourses, in keeping
with the theoretical lens. Passages were sampled for their distinctive use of language,
when they showed how clinicians talked about BPD (as an object) and also when they
pointed to those rules or team practices which underpinned each stance.
Transcripts were examined several times, with essentially three different approaches to
reading and listening. When reviewing the transcripts for the first time, themes were noted.
Then transcripts were examined in more detail for recurring, dominant and deviant themes
(Potter, 2004; Silverman, 2006). At the third level of scrutiny, transcripts were re-visited to
look for themes which were not immediately striking, but perhaps provided a more subtle
response to the research questions. This returning to the transcripts was done with the
deliberate intention of challenging the researchers’ expectations of the research outcomes.
Findings
This analysis begins with a structural examination of the sites where the research was
undertaken, including a discussion of some of the disciplinary roles, team norms and
nuances within each site. After providing an overview of the institutional influences
upon talking about BPD in adolescence, we then consider how this talk was structured.
Conducting diagnosis in context: community versus inpatient settings
Across both sites, the only consistent features of disciplinary roles in relation to diagnosis applied to psychiatry. Psychiatrists were overwhelmingly positioned by clinicians and
also positioned themselves as the head of the team or hierarchy. This rank derived from
the status of psychiatry as a specialty within the medical profession, and those statutory
powers held by psychiatrists to prescribe medication or invoke elements of mental health
legislation (Barrett, 1996). The ascribed power to diagnose accords with Barrett’s observation that power is linked to the capacity to define a psychiatric case.
At site one (community-based service), all clinicians with the exception of the day
programme team leader were expected to make diagnoses, regardless of disciplinary
background. The direct involvement of the psychiatrist was not considered essential in
every diagnostic formulation, however the psychiatrist’s hierarchical position was confirmed as the person with whom to consult, if needing diagnostic clarification or when
facing a ‘diagnostic dilemma’ (Interview, Ryan). Psychiatrists also provided the ‘sign
off’ (Interview, Ruth) on diagnoses made within their teams.
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Disciplinary demarcation between psychology, nursing, social work and occupational
therapy was subtle at site one. The community setting and CAMHS membership at this
site proved more indicative of roles and responsibilities than individual disciplines. The
only ‘jostling for space’ (Parker et al., 1995: 50) was noted with external agencies, or the
neighbouring adolescent inpatient unit, rather than among team members.
Site two (inpatient unit) provided a notable contrast, with the lone psychiatrist considered by all clinicians, including other medical staff, to hold responsibility for making
diagnoses within the unit. Here, disciplinary identities were clearly evident, with nursing
and medical roles adhering more closely to stereotypes, in terms of diagnostic practice.
Of potential significance was the absence of social work, occupational therapy and psychology professionals on the unit at the time of conducting interviews; this represented a
rare period in the unit’s staffing history.
At site two, the way in which care was provided also differed, with nurses ‘on the
floor’ (Interview, Holly) providing a constant care that contrasted with the intermittent
care of community mental health services. Thus, ‘the status of psychiatric nursing, the
distinctiveness of its practice, and the uniqueness of its perspective on the case, were
defined in terms of proximity to the patient’ (Barrett, 1996: 53, emphasis in original).
Proximity had direct consequences for diagnostic talk, with Amy finding that this closeness rendered some diagnostic conversations inappropriate and outside of her nursing
role:
Interviewer:Is it harder being in an inpatient setting than say if you were in the
community?
Amy:I think so because the staff have so many roles on the unit, they’re not
just nurses, they’re counsellors, they’re parents, they’re friends, they’re
siblings, they cover so many … obviously not friends with them but
you know, cover so many different roles in order to keep the kids safe,
contained and try and provide some kind of therapy, that sometimes
maybe it’s not appropriate for nursing staff on the unit to be doing that
kind of stuff I think. It would be better as a community case manager
or something like that where your role is more clearly defined.
(Interview, Amy; 325–333)
Overall, one could quickly surmise the disciplinary background of those clinicians
interviewed at site two, through their comments on proximity and diagnostic responsibility. While psychiatric nurses dominated the unit in terms of numbers, they still jostled for
diagnostic space and role credibility. This site-specific idiosyncrasy proved central to
diagnostic deliberations about BPD.
Not disclosing diagnosis: holding the team line
Within teams, participants established an agreed ‘definition of the situation’ and team
members displayed a tacit set of rules regarding the disclosure of BPD. The working
consensus privileged the claims of particular participants, rather than representing unanimity on an issue (Goffman, 1959).
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At site two, the consultant psychiatrist was considered to have the greatest stake in
decision making and disclosing the BPD diagnosis. This was clearly articulated by Holly:
Interviewer:So if your Consultant Psychiatrist is primarily responsible for making
diagnoses and it sounds like his practice is tending not to talk to the
young person about it, does that filter down to other staff or would
there be some staff here who you think do have those kind of
conversations?
Holly:You don’t tend to because you know that it is, it is not what the
Consultant has diagnosed, so if he’s not formally diagnosing it you
don’t like to follow up and you don’t want to, you don’t want to step on
his toes … I know certain people on the team have broached, you know,
saying you know it looks like you’ve got kind of emerging borderline
personality traits … and that’s not giving them a diagnosis but that’s
giving them some idea of kind of the behaviours that they’re exhibiting
… and I think that’s good but I think you just have to very careful when
you work in a team to keep it very cohesive and that’s not treading on
other people’s toes, especially the ones that are dealing with the risk
factors and are making the diagnosis and being respectful towards
them. (Interview, Holly; 314–332)
The preference of the psychiatrist not to make and disclose this diagnosis was consistently noted by nurses and medical staff on the inpatient unit. References to the danger of
mis-diagnosing and over-diagnosing were audible from most team members. While
Holly also identified occasions when she felt the young person should have been notified
of this diagnosis, she adhered to the team line, bound by the need to maintain cohesion
and respect those discourses of risk and responsibility.
Unsurprisingly, team lines were less rigid at site one, as the differences in setting influenced team dynamics. Here, clinicians functioned at several levels: as solo practitioners;
within their local teams; and also as members of the larger multi-team organization of
CAMHS. Clinicians at this site were permitted to speak about diagnoses including BPD
among clinicians and with clients. Team lines were less directive and tended more towards
organizational ideologies. For example, team leaders hoped, expected and believed that
their team members were ‘cautious and considered’ (Interview, Robyn) and ‘as thorough
and thoughtful as possible’ (Interview, Angela) in making and talking about a BPD diagnosis. Team members aligned with these expectations, frequently positioning themselves as
careful, or ‘very, very, very careful’ when using borderline terminology (Interview, Laura).
While team expectations regarding BPD appeared less prescriptive at site one, there
were still examples whereby clinicians conformed to institutional expectations. For
example, despite objecting to the BPD label, Robyn remained loyal to the DSM terminology endorsed by CAMHS:
I’ve got to say I’m not a fan of the label BPD. I actually tend to think in my head, either a
complex post-traumatic stress disorder symptom[at]ology, but the language I know that I need
to, we kind of need to use is BPD. (Interview, Robyn; 91–94)
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A further example of tension between team expectations and professional identity
occurred when discussing the overall role of psychiatric diagnoses. It was widely
acknowledged by participants that CAMHS policy demanded that a diagnosis be reached
for every client, for routine service reporting purposes. However this requirement posed
a dilemma for some clinicians:
I know diagnosis is very important, it’s a short-hand way of describing a set of presenting symptoms,
it’s often a way of offering funding and linking up funding for, yeah, funding for treatment. I can see
the relevance in a physical setting and I can see the relevance in a, in a mental health setting. But I
just, my whole philosophy on human beings is that they’re always moving forward and changing
which kind of doesn’t fit with the categories and the diagnostic things. (Interview, Eve; 113–118)
In order to manage this tension, Eve adhered to diagnostic formulation, but voiced scepticism
to her clients:
And if you, you’re sat in front of a young person, who says ‘do I have OCD, am I going to be
like this for the rest of my life?’ And you’re talking to a 13 year old, I feel it’s ethical to say
these are diagnoses that are not necessarily based on research solely, they’re based on the
opinions of American psychiatrists, they came about because they needed a way to apportion
insurance funding often. (Interview, Eve; 580–589)
Eve’s ‘performance’ falls into a grey area, not adequately accounted for by Goffman in
his analysis of team roles. However, in Foucauldian terms, Eve challenges the truth status of the DSM and views the young person’s identity as contested territory.
In short, participants fell into line with diagnosis as a practice, but sometimes challenged the authority of the diagnosis, positioning themselves as apart from and critical of
the discourse. At other times participants made use of diagnosis, while drawing upon
qualifying language to establish a sceptical position towards the diagnosis.
Hedges
As noted earlier, the use of language is pivotal in constructing the clinical culture. Semantic
strategies such as ‘hedges’ are words or phrases used to modify the degree of membership
within a statement (Brown and Levinson, 1987), allowing clinicians to either commit or distance themselves from a statement (Fairclough, 1992). Clinicians overwhelmingly advocated
for the use of hedges such as ‘emerging’ and ‘traits’ to respectively preface or follow the term
‘borderline personality disorder’. Lakoff (1973: 471) suggests that hedges are words ‘whose
job is to make things fuzzier or less fuzzy’. The use of hedges in adolescent applications of
the BPD diagnosis served to make things fuzzier, as a way of softening (Interview, Ruth) or
cushioning (Interview, Robyn) the diagnosis. Yet, they were also relied upon in an attempt to
define a grey zone, or as a way of giving the benefit of the doubt (Interview, Simon).
The term ‘traits’ worked to offset the permanency otherwise associated with a personality disorder diagnosis. Scott, for example described his rationale for employing hedges:
Interviewer:Do you see a difference in the terminology between saying say this
person has BPD and this person has BPD traits or emerging BPD?
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Scott:[sigh] I think it’s better to have traits, I think you know, the sake of
splitting hairs but I think it’s actually, it’s a lot more beneficial for an
adolescent just to have traits or it may be emerging than to have a full
blown I have it and that’s it.
Interviewer: Yep, why?
Scott:It’s too final because it can, emerging and, and traits means it’s just,
you have some of these areas that potentially could change and I think
that’s a much nicer, I, you know, I think adolescent psychiatry is all
about hope, you have to have the hope and if you don’t provide hope,
if you say something’s it and final that’s it, you know. (Interview, Scott;
154–166, emphases in original)
For Holly, hedges allowed her to continue to talk about and describe BPD. Within her
account, Holly also makes reference to an external and prohibiting authority, though the
identity of this authority remained nebulous:
Interviewer: Do you think that terminology like emerging or traits is useful?
Holly:I think it is ’cos, it’s, it’s good to be able to identify because you can’t,
because they don’t like to give a diagnosis, but if you, if we weren’t
able to say that these are emerging traits and things like that you
couldn’t pinpoint them, then it’s very hard to, to work with what’s
going on. (Interview, Holly; 57–61)
Owen was the only clinician who objected to the use of hedges describing them as
‘just a bit cowardly, I think it’s just hiding behind the fact that you can’t give a diagnosis
’til they’re 18, isn’t it?’ (Interview, Owen; 206–208)
While we anticipated that hedges would be commonly used to buttress the BPD diagnosis, the ubiquity of this practice was surprising. Identifying the origins and proliferation of this practice proved challenging, as this modified vocabulary for adolescents
seems to have occurred in isolation from the DSM, which defines the BPD diagnosis.
One may surmise that a customized CAMHS vocabulary emerged in clinical practice as
a resistance to the generic criteria of BPD, which clearly delineates between normal and
abnormal, and may be considered a poor fit for the developing adolescent. The use of
hedges indicates a functional demand for descriptors regarding this diagnosis in adolescence, yet a reluctance to embrace categorically the personality disorder vocabulary and
its implications. Another strategy in language will now be examined; the role of borderline talk in clinical practice.
Borderline talk
Returning to Foucault’s enunciative modalities, site two provided a glaring example of
who was accorded the right to speak freely about BPD. The consultant psychiatrist was
authorized to name BPD at any time and in any environment, both among clinicians, and
to clients and families. Team members however, were restricted in their enunciative
forums. Overall, clinicians in this sample tended not to talk to clients about BPD. This
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restricted their audience to other clinicians. Using Goffman’s (1959) terminology, nursing staff were limited to discussing BPD backstage, rather than front stage.
Backstage talk about BPD was described as common by interview participants at site
two, with Amy describing a typical example:
Well I guess during handover or even just within the office environment, if people were just, if
young people were displaying behaviours that someone thought was that kind of personality
disorder traits then it might be discussed, and I guess if it’s talked about enough people start to
get the idea even if the person hasn’t got the diagnosis that they, they label them anyway to a
degree. (Interview, Amy; 149–153)
Nurses showed that talk about BPD may be received differently, depending upon the
backstage region. Thus there were degrees of backstage, whereby nursing handovers, for
example, represented a setting where it was relatively safe to use borderline descriptors,
despite individual staff preferences. But during backstage discussions attended by the
consultant psychiatrist (i.e. team handovers, office discussions, etc.) the informal mention of borderline traits became risky:
Interviewer: Do the terms get used much verbally if not always documented?
Holly:
Yeah I think they get used verbally more than they get documented.
Interviewer: Can you give me an example?
Holly:Just when there’s, there’s situations on the unit where their behaviours
are, are a bit more destructive or out of control. I know staff here will
mention that they, they seem to have emerging traits and you’ll say that
to the Consultant and, and the Consultant’s very quick to turn around
and say well you need to tell me exactly what they are because I don’t
want them being labelled. So I s’pose, and I think that’s, it’s important
too that he does do that, that we’re not just giving out a label for, for
behaviours that can just be adolescent, behaviours, so … (Interview,
Holly; 108–120)
Lester (2009: 285, emphases in original) coined the phrase ‘borderline talk’ to describe
the
mode of everyday discourse among clinicians that ascribes BPD as shorthand to clusters of
behavioural and interpersonal concerns. … It can be explanatory, accounting for a client’s
behaviour … It can be cautionary, as a way of preparing another clinician for an encounter …
It can also become a way for therapists to communicate to each other their personal struggles
or even burn out.
Participant accounts within this research support Lester’s hypotheses. For example,
when asked whether borderline talk was useful, Holly (and others) identified a cautionary usefulness:
It is ’cos sometimes you can be caught out and when they can be staff splitting and manipulating
and things like that, and it just keeps you on your toes, it makes you more aware that, that this
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is what the young person has been kind of known to do and, yeah, it just, it does, it does make
you more aware. (Interview, Holly; 185–188)
At site one, borderline talk was mentioned, with Catherine reporting the practice of
people talking ‘about it professionally, oh with other professionals sorry, but actually not
with the young person’ (Interview, Catherine; 241–242). In alliance with site two, Alex
described an explanatory use of borderline talk in the community setting:
Ah we’ve got to be able communicate these ideas somehow. And ah, ah you know I, once again
I think as long as we understand you know, as long as language is used in a way that ah the best
interests of the client you know are kept to the fore, then I think it is productive. But when it’s
used to close doors and you know to, to shut out and to ah to discount, ah that’s when it’s
negative. (Interview, Alex; 495–499)
However, generally there was cohesion around the application of borderline terminology within CAMHS and ‘borderline talk’ served fewer functions than on the inpatient
unit.
Borderline talk was never acclaimed as entirely positive, with all clinicians also
describing disadvantages to its use. Patrick, a community psychiatrist (from site one),
described this predicament as a ‘two edged sword’, seeing utility in the borderline concept, but also the potential for it to be used in a ‘scathing way’.
Furthermore, while Dana (a psychiatry trainee at site two) described a prescriptive
function to borderline talk, she also saw this as reductionist and negative:
Often the, the conversation comes up in terms of admissions, so if we’ve got a transfer of a
patient who we’ve had before who has marked borderline traits for example, I think there’s an
assumption that their admission is going to be difficult, that the milieu of the ward is going to
change, and that they won’t necessarily remain as an inpatient for a long time. So I think that
it’s, it’s a way of describing some of the difficult patients without having to actually go through
specific issues so there’s a lot of assumptions that are made and so forth, but it’s always said in
quite a negative way. (Interview, Dana; 446–452)
Owen, Scott and Michael, three of the senior nursing and medical staff at site two,
primarily objected to borderline talk because of the potential to stigmatize the client
among staff. Owen suggested that it was used by people who were not qualified to make
diagnoses, and sometimes to ‘opt out’ of working with these young people. As nurse
manager, Scott felt that borderline descriptors prevented people from going beyond the
diagnosis, to what the person was really about. His suggestion that it often came from
nurses who were in a ‘bad place’, aligned with Lester’s (2009) function of communicating personal struggles. The psychiatrist, Michael was ‘not in favour of’ the practice of
borderline talk and believed it was often used in a dismissive way. Regardless of this
stance by three of the most senior staff on the unit, all acknowledged a well-entrenched
pattern of borderline talk among clinicians. While Michael retained sole authority to
diagnose BPD formally and speak uncensored in both front- and backstage, nursing
staff resisted this psychiatric dominance, through their continued employment of borderline talk.
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The persistence of borderline talk may reflect nursing’s reliance on the oral culture of
knowledge transmission. In handover for example, nurses draw upon stereotypical identities
to provide their colleagues with a ‘sense of the lie of the land’ (Parker and Wiltshire, 1995:
148). Such formulations are necessarily brief and not always erudite (Hamilton and Manias,
2009). While medical and some nursing staff objected to the imprecision of stereotypical
‘borderline’ constructions, the functionality of borderline talk remained powerful, as a tool
to explain, caution, communicate personal struggles and inform treatment decisions.
Thus, the territory surrounding borderline talk was contested, with disciplinary techniques traversing both staff groups. Through their clinical gaze and subsequent determinations of treatment and length of stays, clinicians used borderline talk to regulate
adolescent inpatients. Running counter to these techniques was the exercise of the psychiatrist’s powerful gaze upon staff, in an attempt to clamp down on the use of borderline
talk. Michael also sought to introduce a screening tool, to ensure more accurate use of the
borderline diagnosis. Against the authority of Michael’s position, ‘borderline talk’ may
be more appropriately termed a tenacious discourse.
‘How’ to talk to adolescents – reframing BPD
The BPD label provided a clear example of psychiatric terminology which achieves a very
low level of precision in its attempts to describe moods and mental states (Linnet, 2004).
Clinicians struggled with the semantics of BPD, especially when talking with adolescents.
Its inherent ambiguity was considered problematic by several clinicians. Simon suggested:
I think it’s hard for people to know what borderline means. I mean I’ve certainly had patients
ask me what does it mean that I’m borderline? Ah, and you sort of explain it but, it … doesn’t
sort of make sense to people, in the way that, say depression does, that’s sort of a more
understandable sort of diagnosis. (Interview, Simon; 248–253)
As a result of dissatisfaction with the BPD label, clinicians sought to ‘fashion and
tailor’ (Interview, Simon), ‘re-frame’ (Interview, Margot) or ‘steer away from’ (Interview,
Robyn) the words borderline personality disorder. Robyn used sensory metaphors to
describe her position, preferring to describe diagnosis and ‘flesh it out, as opposed to
always just going bamo, this is it’ (383–384). Robyn noted the importance of giving
people time to ‘digest’ their diagnoses and felt that BPD was a ‘whack of a diagnosis to
give someone, particularly as they hit the adult system’ (121–122, emphases added).
Preferring to offer a behavioural or symptom descriptor was a strong rhetoric throughout clinician interviews. Natasha spoke of her tendency not to name the BPD diagnosis,
instead ‘naming the behaviour, the consequences, the interpersonal relationships, the,
kind of the symptoms of, without giving it the label’ (Interview, Natasha; 505–506).
Clinicians were consistently wary of naming diagnoses, of adopting a vocabulary that
authorized ‘comparison, generalization and establishment within a totality’ (Foucault, 1989:
139). Natasha worried about the permanent connotations of a personality disorder label:
I don’t know, but it feels a bit like there’s nothing for them to work towards, there’s nothing for
the therapy to work towards if it’s given a label that feels permanent. If it’s given a descriptor
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about behaviour and interactions, there’s something more fluid about that, we can change your
behaviour, we can work on our interactions, but our personality is kind of stuck. (Interview,
Natasha; 519–523)
At site two, the nurse manager Scott reiterated those rules governing disclosure of
BPD:
What we do is, what we would do is identify issues and patterns of behaviour and feed back to
a young person but we don’t neccess- we don’t put it in diagnostic terms, and I don’t actually
think in adolescents having diagnostic terms is often that useful for certain disorders. I think it’s
better to look at the problems. What’s causing your problem? Look at the strengths and
weaknesses of a kid and then look at that. (Interview, Scott; 47–51, emphasis in original)
This position aligns with behavioural therapy, which originated through the need to treat
those disorders not considered amenable to physical or pharmacological treatment, or those
people ‘not sick’ within psychiatry’s domain (Rose, 1989). When defined in behaviourist
terms, personality disorders are problems of behaviour and able to be re-shaped.
Accordingly, clinicians in this study saw adolescent personalities as ‘malleable’ (Interviews,
Ryan, Laura, Margot), ‘still forming’ (Interview, Margot), ‘developing’ (Interview, Laura),
‘maturing’ (Interview, Holly) and ‘in a state of flux’ (Interview, Michael). The opportunity
to re-shape personality and watch for improvement was also considered as a hallmark of
adolescence, linked closely to the expression of clinical optimism and hopefulness:
And that’s the biggest difference I see in CAMHS versus adult, that’s why I work in CAMHS
because I know things can change, I’ve experienced that, I’ve been a part of the change, and I
know it can, and young people do evolve, they develop, they grow up, they mature, thank God!
(Interview, Angela; 382–386)
Overall, clinicians consistently re-shaped BPD when talking to adolescents, finessing
language to accord with their own preferences and to match the perceived needs of their
adolescent clients. Resistance to disclose the BPD diagnosis stemmed from both dissatisfaction with this label and also a desire to retain hopefulness, which was better served
by lay definitions of problems.
Discussion
The study shows how the category of BPD exists as an object of psychopathology within a
complex group of social and power relations. The differences in roles across sites highlighted
the power of the setting to determine clinician roles, team functioning and ways of interacting
with adolescents. For nurses in an inpatient unit, the setting framed their roles in relation to
diagnoses, organizing them to observe and report diagnostic features ‘up the line’ to the psychiatrist. Prohibitions to diagnose and restrictions on talking about the BPD diagnosis were
striking and consistent. The setting also dictated the way in which nurses engaged with adolescents. Their roles were multifaceted; arising from their proximity to adolescents over time
and space and the concomitant responsibility they carried to manage safety and behaviour.
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Practice in the inpatient unit was consistent with Barrett’s (1996: 48) description of a
psychiatric hospital, where, ‘although other professions had an informal warrant to
advance diagnostic opinions when talking with their colleagues, only psychiatry was
licensed to make formal diagnostic statements of illness that could be entered into the
official case record’. In part, this distinction proved to be a significant point of difference
between the sites, with such power differentials much more visible at site two.
Furthermore, the informal warrant to make diagnostic statements manifested at site two
in the form of borderline talk, as detailed. In addition to providing a summary of the utility of borderline talk, this discussion also considers the way in which the identity work
done by clinicians impacted upon adolescent identities – allowing both agents room to
move.
The utility of the BPD diagnosis among clinicians
The findings indicate how little scope there was for frank use of the diagnosis of BPD in
the adolescent clinical setting. With BPD in particular, clinicians tended to talk to clients
in terms of symptoms, problems and behaviours rather than use diagnostic speak. By
focusing upon anything but diagnosis, in both clinical formulations and communications, clinicians often preferred an approach which ‘remained at the level of the problem
itself’ (Rose, 1989: 234).
Rhodes (1991) described the status of diagnosis in an acute psychiatric unit as contradictory; central and peripheral, key to defining psychiatric patients, yet often valued
more for strategic rather than medical purposes. Rhodes (1991: 95, emphasis in original)
watched medical students ‘learn that diagnosis was true, useful and tentative, even
meaningless’. These observations accord closely with the findings of this research. At
both sites, clinicians in this project did not always herald diagnosis as true, however they
did identify dichotomies of diagnosis; as necessary and unnecessary, helpful and unhelpful, contributing to and detracting from their ability to know a young person. Overall,
diagnosis was imperfect and fallible, and therefore clinicians were judicious in their use
of diagnoses.
The imprint of clinician identity work upon adolescent identities
Clinicians and adolescents were linked together in a disciplinary space, where both parties were active in looking over and being looked over (Dreyfus and Rabinow, 1982).
Clinicians looked over each other in the diverse disciplinary spaces of inpatient units, in
team meetings and handovers. Their gaze was astutely focused on attitudes and language
use in the highly charged realm of BPD. Clinicians powerfully disciplined each other, in
their silences and in their oblique use of language associated with the diagnosis of BPD.
Clinicians found room to adopt positions of scepticism around the meaning and utility of the BPD diagnosis, a positioning identified by Whooley (2010) as common also
among a sample of US psychiatrists working with a range of DSM diagnoses. At site
two, clinicians primarily positioned themselves as not authorized to use the BPD diagnosis, thus making space for reservations. At both sites, clinicians resisted the permanent connotations of personality disorder diagnoses. While clinicians could not avoid
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interacting with the issue of diagnosis as they appraised adolescents in their care, their
gripe was with the limits of the BPD diagnostic nosology itself. In our analysis, and in
line with the DSM IV-TR (APA, 2000), personality traits in Axis II diagnoses were
taken to infer permanency in contrast with those episodic states in Axis I diagnoses.
However, used by clinicians in everyday practice, the term ‘traits’ functioned as a
hedge. It denoted only partial achievement of diagnostic criteria and the incomplete
fulfilment of a BPD identity, thus assembling an identity which could be discredited
over time. So the notions of traits and of emerging diagnosis acted as qualifiers in
speech, disrupting or postponing claims to diagnostic permanency. The unanimous
preference for hedges preserved the clinicians’ own sceptical identities as well as producing room for adolescents to move.
Transitional identities: allowing room for adolescents to move
In the course of this analysis, it became evident that when clinicians made decisions not
to talk to adolescents about emerging BPD, it was rarely as a result of disregarding the
adolescent position. In fact, clinicians were often positioned ‘between a rock and a hard
place’ and their decisions overwhelmingly reflected their need to work with fallible diagnostic categories.
As indicated in the findings, clinicians predominantly sought to resist any vocabulary
which positioned adolescents within a totality. Instead, behavioural descriptors were
relied upon for their ability to emphasize temporality. Behaviour can be thought of as
fleeting, occurring in time and space, as a phenomenon that could pass and be left behind.
Description of phenomena as ‘behaviour’ links to both lay and normal psychology perspectives of problems of adolescence, denoting temporary aberrations, with the potential
to be outgrown or discarded.
The course of BPD resembled a pathway or trajectory within clinician accounts. The
act of closure on a diagnosis of BPD was loaded with prognostic meanings which did not
hold true, alongside their understandings of the adolescents in their care. By resisting
foreclosure on a BPD diagnosis, clinicians could allow troubled adolescents who met
some criteria to defy the BPD trajectory with which they were familiar.
Conclusion
We began this article by noting the frustration experienced in clinical settings, where the
BPD diagnosis was routinely not disclosed to adolescents. Through the process of undertaking interviews, it became clear that a black and white stance (i.e. either for or against
disclosure) would nullify the research. In fact, the complexity, contradiction and flaws
inherent in this diagnostic category essentially drove the practices identified in this
research. The findings richly illustrate clinicians negotiating diagnostic talk in a situation
of uncertainty and with vulnerable populations. Discursive strategies to work around the
diagnosis operated at the level of individual practitioners, clinicians grouped by discipline and whole teams in particular settings. These can be seen as robust and everyday
expressions of the enduring contest surrounding psychiatric diagnoses in general and
BPD more than most.
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Author biographies
Kristy Koehne RPN, BN(Hons), PhD specialises in Child and Adolescent Mental Health in
research and clinical practice. In addition to her PhD examination of borderline personality disorder discourse in adolescence, research interests include self-harm, suicidality and the early intervention construct in psychiatry.
Bridget Hamilton RN, BN(Hons), PhD is Senior Lecturer at the Department of Nursing, The
University of Melbourne. She is connected to clinical practice as a Clinical Nurse Consultant at
St.Vincent’s Mental Health, Melbourne. Her research centres on post-structural analyses of everyday practices in healthcare. She is interested in law and coercion, and in amplifying diverse voices
in health care settings.
Natisha Sands (PhD) is Associate Professor at the School of Nursing and Midwifery, Deakin
University. She investigates mental health triage clinical practice, mental health care in the emergency department and clinical risk assessment. She is committed to developing evidence-based
frameworks and education programs to support clinicians in improving the quality and consistency
of triage and practice.
Cathy Humphreys BSW, PhD is Professor of Social Work in the Department of Social Work, The
University of Melbourne. Her research interests lie in the areas of domestic violence and child
abuse including the impact on mental health and child development.
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