How women diagnosed with Borderline Personality Disorder negotiate identity in relation to risk

313 Pages·2017·1.54 MB·English

by  Michael Huggett

How women diagnosed with Borderline
Personality Disorder negotiate identity in
relation to risk

Michael J Huggett

A thesis submitted in partial fulfilment of the requirements of the University
of Brighton for the degree of Doctor of Philosophy

2016
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Abstract

This thesis examines how women with a diagnosis of borderline personality disorder (BPD)
negotiate their identity in relation to risk, also referred to as their ‘risk identity’. This is
defined as, ‘…the view people have of themselves and project to others in their talk and
actions in relation to risk and risk taking’.

The theoretical perspective which underpins the study is informed by ontological realism,
epistemological discursive/linguistic social constructionism, and an ideological critical
liberatory position primarily derived from the work of Foucault (1978; 1991a; 1991b; 1998;
2002; 2008a; 2008b; 2009). This perspective informed the decision to adopt email interviews
as a method for generating appropriate texts for analysis. Eight women diagnosed with BPD
were interviewed over a period of ten months.

Adopting a critical emancipatory methodology which incorporated feminist principles of
research, Lather’s (1991) adaptation of Van Maanen’s (1988 cited in Lather 1991) ‘four
tales’ was employed to view and analyse the texts from four theoretical perspectives; a
‘Realist Tale’, a ‘Critical Tale’, a ‘Deconstructivist Tale’, and a ‘Reflexive Tale’.

By ‘layering’ these tales, the findings revealed sets of tensions discernable within the context
of interactions with staff, the nature of services, and the wider material and discursive
resources at play which inform how risk identities are negotiated. Converging Western
discourses of the subject, binary gender discourse, neoliberal discourse, ‘psy’ discourses,
and discourses around motherhood were found to be key discursive resources through which
risk identity is produced, resisted and projected.

In addition these to broad discursive findings, the study also contributes to the existing
empirical literature that focuses on the lived experience of those with a BPD diagnosis.

A conclusion is drawn that women with a BPD diagnosis not only receive a label which
discursively excludes them from being able to be viewed as a ‘good subject of psychiatry’
(and hence leads to them being viewed as dangerous and risky), but that their difficulties and
need for relational approaches to manage risk and promote recovery run counter to the way
that mental health services are structured in the current neoliberal era.
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Table of Contents

ACKNOWLEDGEMENTS .................................................................................................. 6
DECLARATION .................................................................................................................. 7
CHAPTER 1 INTRODUCTION .......................................................................................... 9
CHAPTER 2 LITERATURE REVIEW ............................................................................. 33
CHAPTER 3 THEORETICAL PERSPECTIVE ................................................................ 57
CHAPTER 4 METHODOLOGICAL APPROACH AND METHODS ............................. 71
CHAPTER 5 ANALYSIS – THE REALIST TALE ......................................................... 103
CHAPTER 6 ANALYSIS – THE CRITICAL TALE ...................................................... 135
CHAPTER 7 ANALYSIS – THE DECONSTRUCTIVIST TALE ................................. 167
CHAPTER 8 ANALYSIS – THE REFLEXIVE TALE ................................................... 201
CHAPTER 9 DISCUSSION AND CONLUSION ............................................................ 211
REFERENCES .................................................................................................................. 253
APPENDIX 1 – DSM-V CRITERIA FOR BPD .............................................................. 277
APPENDIX 2 – LITERATURE REVIEW SEARCHES ................................................. 278
APPENDIX 3 – RESEARCH WEBSITE ......................................................................... 280
APPENDIX 4 – MENTAL HEALTHY RECRUITMENT ARTICLE ............................ 284
APPENDIX 5 – UPDATE EMAIL EXAMPLES ............................................................ 285
APPENDIX 6 – CONSENT FORM ................................................................................. 288
APPENDIX 7 – ETHICS APPROVAL ............................................................................ 292
APPENDIX 8 – EXAMPLE OF INTERVIEW TEXT (SUSAN EXTRACT) ................. 293
APPENDIX 9 – EXAMPLE SECTION OF MICROSOFTWORD DOCUMENT
IDENTIFYING INITIAL THEMES WITHIN THE TEXTS (SUSAN) ........................... 302
APPENDIX 10 – EXAMPLE SECTION OF ANALYTIC TABLE ................................. 308

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Acknowledgements

I’d like to thank my supervisors, Dr. Graham Stew and Dr. Kay Aranda, for providing the
ideal level of both academic and personal support that I have needed over the course of this
project. I’d also like to thank all those I met at ‘Love Lodge’, both staff and residents, for
teaching me how to nurse.

My wife Caroline has endured many hours of proofreading and listening to me ramble about
my ideas, concerns, and confusions over the years. Given the themes of the research, the
irony of her being saddled with the majority of the housework whilst I completed the writing-
up phase of the project was not lost on either of us, so thanks Boo x

Thanks to all my family, friends, and Charlie the cat for generally keeping me going. Finally,
and most importantly, a big thank you to the participants who took part in this project, I hope
I’ve done justice to your wonderful contributions.

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Declaration

I declare that the research contained in this thesis, unless otherwise formally indicated within
the text, is the original work of the author. The thesis has not been previously submitted to
this or any other university for a degree, and does not incorporate any material already
submitted for a degree.

Signed

th
Dated 29 August 2017

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Chapter 1 Introduction

My aim in this opening chapter is to introduce the reader to my study. To achieve this,
orientation will be given as to my professional background, the risk-dominated culture of
modern mental health services, the women subject to the diagnosis of BPD and the historical
background and working definitions of the key concepts of BPD, identity and risk. Once
these details are delineated, the chapter will conclude by formally stating the purpose, overall
aims and objectives of the research.

Before undertaking this task, it is first necessary to introduce the reader to the style in which
this thesis is written since, as will be seen, this is key to the overall rigor of the undertaking
and is firmly rooted in my theoretical position.

Writing style
Throughout the thesis I will utilise the first person pronoun on the understanding that the
implication of detached objectivity rooted in traditional positivistic research writing is not
only an epistemological impossibility but also a means by which power, in the Foucauldian
sense of ‘power/knowledge’ (Foucault 1991a), hides its operations within discourse. As an
imperfect gesture towards an openness as to the necessary and unavoidable biases that frame
my exploration of the research themes and the investments I have in producing knowledge,
I deliberately insert myself into the text of the thesis following the principles of reflexivity
embedded in reflective research. As Alvesson and Sköldberg (2000) characterise reflective
research:

“Reflective research has two basic characteristics: careful interpretation and
reflection. The first implies that all references – trivial and non-trivial – to empirical
data are the results of interpretation. Thus the idea that measurements, observations,
the statements of interview subjects, and the study of secondary data such as statistics
or archival data have an unequivocal or unproblematic relationship to anything
outside the empirical material is rejected on principle … The second element,
reflection, turns attention ‘inwards’ towards the person of the researcher, the
relevant research community, society as a whole, intellectual and cultural traditions,
and the central importance, as well as problematic nature, of language and narrative
(the form of presentation) in the research context” (ibid pp5-6).

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Mental health nursing as a profession
The professional role of a mental health nurse in the UK is defined by the Nursing and
Midwifery Council (NMC), the statutory body established in 2002 by Parliament as the
regulator for the nursing and midwifery professions. Whilst the NMC Code of Practice sets
out general ‘standards of competence’ applicable to all nurses and midwives under the four
areas of professional values, communication and interpersonal skills, nursing practice and
decision making, and leadership, management and team working, it also provides specific
standards for each branch of nursing under these headings. For mental health nurses, it gives
the following guidance for each of the competences:

Professional Values
“Mental health nurses must work with people of all ages using values-based mental
health frameworks. They must use different methods of engaging people, and work
in a way that promotes positive relationships focused on social inclusion, human
rights and recovery, that is, a person’s ability to live a self-directed life, with or
without symptoms, that they believe is meaningful and satisfying”.

Communication and Interpersonal Skills
“Mental health nurses must practice in a way that focuses on the therapeutic use of
self. They must draw on a range of methods of engaging with people of all ages
experiencing mental health problems, and those important to them, to develop and
maintain therapeutic relationships. They must work alongside people, using a range
of interpersonal approaches and skills to help them explore and make sense of their
experiences in a way that promotes recovery”.

Nursing Practice and Decision Making
“Mental health nurses must draw on a range of evidence-based psychological,
psychosocial and other complex therapeutic skills and interventions to provide
person-centred support and care across all ages, in a way that supports self-
determination and aids recovery. They must also promote improvements in physical
and mental health and wellbeing and provide direct care to meet both the essential
and complex physical and mental health needs of people with mental health
problems”.

Leadership, Management and Team Working
“Mental health nurses must contribute to the leadership, management and design of
mental health services. They must work with service users, carers, other
professionals and agencies to shape future services, aid recovery and challenge
discrimination and inequality”

(Nursing and Midwifery Council 2015 pp18-19).

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