Women and Borderline Personality Disorder

The main claims of Women and Borderline Personality Disorder are that BPD is a feminized category and that it illuminates how contemporary treats gender.  Wirth-Cauchon adopts a feminist stance and explains that her approach is akin to Susan Bordo’s analysis of anorexia nervosa as the “crystallization of culture” in Unbearable Weight: Feminism, Western Culture, and the Body, and she argues that BPD plays a very similar role in psychiatry today to that played by hysteria in the late nineteenth and early twentieth centuries.  Her work is strongly influenced by Elaine Showalter’s classic work The Female Malady: Women, Madness, and English Culture 1830-1890, Judith Herman’s influential Trauma and Recovery, Jane Ussher’s Women’s Madness: Misogyny or Mental Illness, Dana Becker’s Through the Looking Glass: Women and Borderline Personality Disorder, and Janice Cauwels' Imbroglio: Rising to the Challenge of Borderline Personality Disorder.  She also draws heavily on a 1997 article published in Affilia by Mary Ann Jimenez, entitled “Gender and Psychiatry: Psychiatric Conceptions of Mental Disorders in Women, 1960-1994.”

BPD first entered into the American Psychiatric Association’s Diagnostic and Statistical Manual in 1980, and currently 15-25% of hospital and outpatient cases receive the diagnosis in the US.  About three quarters of those diagnosed with BPD are women.  Wirth-Cauchon’s aim is not to explicitly deny that there is such a thing as BPD or that women who are diagnosed with the disorder experience distress.  Rather, she wants to, quoting Kathy Ferguson, “deconstruct meaning claims in order to look for the modes of power they carry and to force open a space for the emergence of counter-meanings” (p. 27).  Wirth-Cauchon draws primarily on feminist theory, psychoanalytic theory, and discussion of memoirs by people diagnosed with BPD.  Her writing style is for the most part very clear and she does not get bogged down in obscure terminology, although it is disappointing that she devotes very little space at the end of her book to the practical applications of her ideas.

There are six chapters.  After the first introductory chapter that explains her stance and methods, Wirth-Cauchon devotes the second one to a history, or Foucaultian genealogy, of the borderline diagnosis.  Wirth-Cauchon has not done a great deal of original research into this history, but she provides an excellent summary of the literature on the topic, and her ability to explain clearly the complex relations between different ideas is remarkable.  She makes it clear that there is no single agreed conception of BPD and there are many different factors have led to the current thinking about the disorder.  She emphasizes that BPD has a negative connotation, and is especially used to as a synonym for “difficult patient” and may be most often applied to women who engage in behavior that goes against typical feminine roles, such as acting out of rage or being sexually assertive.  She also argues that BPD has a higher incidence among people who have suffered sexual abuse, and more women are abused than men. 

In chapter three, Wirth-Cauchon summarizes some of recent theory concerning female gender identity.  She relates this to women who have been diagnosed with BPD, using cases from clinical literature of psychoanalysis and psychotherapy.   Their selves are not unified, but instead are incoherent, split, or empty, dissolving or vacillating.  Men diagnosed with BPD tend to be seen as rigid and defensive, by contrast.  The next chapter goes into case histories in even greater detail concerning the fragmentation of selfhood, using a variety of sources.  She devotes many pages to the narrative in Every Day Gets a Little Closer: A Twice-Told Therapy by Irvin Yalom and Ginny Elkin and also to a case from Yalom’s patient Marge in one of the cases in Love’s Executioner and Other Tales of Psychotherapy.  Wirth-Cauchon argues that “Marge’s split self can be understood as the embodiment or personification, in exaggerated form, of the dual image of women in Western perception” (p. 142).  The rest of the chapter is devoted to discussion of Susanna Kaysen’s Girl, Interrupted and Jane Wanklin’s Let Me Make It Good.  Wirth-Cauchon’s interpretation of Kaysen’s account of her hospitalization at MacLean Hospital with a diagnosis of BPD is that Kaysen is “at odds with normative femininity” and that her only option is resistance that takes the form of paralysis (p. 150).  Wirth-Cauchon mentions with approval Kaysen’s critical discussion of the diagnosis of BPD. 

Wirth-Cauchon’s interpretations of cases raise a central question: is she saying that women diagnosed with BPD have no mental illness, but are in fact reacting in rational ways to contradictions in the social roles given to women and the diagnosis of BPD pathologizes a normal reaction, that these women do have a mental illness, which is caused by the tensions within social expectations of women, or that they have a mental illness which may or may not be caused by gender roles, but which can help us understand the self-contradictions and sexism of modern thinking about gender?  She clarifies her position somewhat in the fifth chapter, which deals with women’s rage. She makes clear that she believes that patriarchal culture does contribute to women’s rage, and she argues that women’s rage is meaningful.  She does not go so far as to say that, in a non-patriarchal society, women would never be diagnosed with BPD, although at various points she seems to come close to such a claim.

In the final chapter, Wirth-Cauchon endorses Marta Caminero-Santangelo’s view in The Madwoman Cannot Speak: Or Why Insanity Is Not Subversive that it is a mistake to ally feminist accounts too closely with antipsychiatry, to interpret madness as a political response, and to ignore the suffering of individual women.  Wirth-Cauchon is clear that she rejects a disease model of BPD, and she endorses a socially aware therapeutic approach to helping women diagnosed with BPD.  She approvingly discusses narrative, social constructionist and postmodern psychotherapy that enable patients to find new ways to tell their stories and to abandon fixed accounts of selfhood and enable the emergence of the patient’s subjectivity.

Women and Borderline Personality Disorder is impressive in its synthesis of many different ideas.  The strength of the book lies in its ability to provide an interesting perspective.  Readers who are not already sympathetic to feminist interpretations of society and its problems will probably find that there is little in this book to change their opinion, and it is disappointing that the author does not provide much in the way of evidence for the truth of the interpretation.  It would be helpful for therapists to know whether feminist approaches to treating BPD were more effective than other approaches, and at a minimum, the author could have done more to explain how feminist psychotherapy would differ from other forms of psychotherapy.  Nevertheless, both clinicians and people diagnosed with BPD may find much of value in Wirth-Cauchon’s thoughtful and provoking analysis.

© 2003 Christian Perring. All rights reserved.

Christian Perring, Ph.D., is Chair of the Philosophy Department at Dowling College, Long Island, and editor of Metapsychology Online Review. His main research is on philosophical issues in medicine, psychiatry and psychology.