Journal of Contemporary Psychotherapy, Vol. 34, No.

3, Fall 2004 (°
C 2004)

Between Subjugation and Survival: Women,

Borderline Personality Disorder and High
Security Mental Hospitals
Sam Warner and Tracey Wilkins

Women in high security mental health care are frequently diagnosed with border-
line personality disorder. Such women commonly report histories of child abuse,
in particular child sexual abuse, and the vast majority also self-harm. In this
paper, we draw on social constructionist theory to develop a framework for un-
derstanding these women, the effects of abuse and the reasons they self-harm. We
demonstrate how a social model of intervention provides a comprehensive frame-
work for identifying and exploring relevant factors within therapy. We argue that
diagnostic categorisation has limited utility in directing therapeutic work with this
particular group of women, because it directs attention away from the social world
to internal pathology. We demonstrate that it is with reference to women’s past
and current relationships that “borderline” behaviour can be understood to be
meaningful and partially adaptive. We conclude that treatment is more usefully
organised around and directed towards those factors, such as abuse and self-harm,
that are implicated in women’s ongoing relationship difficulties.
KEY WORDS: borderline personality disorder; social constructionism; child abuse and self-harm.

INTRODUCTION: WHY SOCIAL CONSTRUCTIONISM?1

The terms we use, the questions we ask, and how we determine which ques-
tions are pertinent to ask, shape our understanding of that which we wish to address
and also influence our responses towards it (Warner, 2003a). In this sense, what we
understand to be real is socially constructed through language (Foucault, 1990).

Address correspondence to Dr. Sam Warner, Department of Psychology and Speech Pathology, Fac-
ulty of Communication Studies, Law and Education, Manchester Metropolitan University, Elizabeth
Gaskell Campus, Hathersage Road, Manchester, M13 OJA, UK; e-mail: Sjwarner@aol.com.
1 This paper is based on research and practice conducted in British high security mental hospitals. The
quotes, except where otherwise stated, are taken from research conducted by Warner (1999).

265
0022-0116/04/0900-0265/0 °
C 2004 Human Sciences Press, Inc.
266 Warner and Wilkins

Hence, what we understand to be the “real problem” for women who are con-
sidered to be “borderline” is already indicated through how we describe and talk
about them. If we talk about their “borderline disorder” this invites a focus on the
specific woman and her internal mental pathology. If we talk about women’s life
experiences this extends concern from the specific woman to include issues, such
as how others interact with her. In this paper our first question, then, is how does
a diagnosis of borderline personality disorder help or impede our ability to work
therapeutically with women in secure care?
From a social constructionist perspective there can never be one perfect ac-
count of personality disorder or method of intervention. This is because our un-
derstandings and practices, and the values these have, change according to history,
social context and individual concerns. However, just because any evaluation is
relative, this does not mean that we cannot be critical. We can still develop frame-
works that provide a structure for asking searching questions about our practice. To
this end we adopt the framework developed in “Visible Therapy” (Warner, 2001;
2003b). According to this approach, the value in particular perspectives can be
found in their ability to promote change and development through identifying the
hidden structures that secure social and personal marginalisation.
The idea is that people become stuck in unhappy ways of being because they
are unable to see how the reality of their lives is shaped, not simply by their ex-
periences, but by their understanding of their experiences, and the feelings these
engender. The concern is with the shifting relationships between thoughts, feel-
ings and behaviour. As such, this approach contrasts with other therapeutic models
that tend to concentrate on one area of communication such as thoughts within
cognitive therapy. The aim is to make the invisible visible—to explore how an
individual’s sense of what is real is shaped and structured. Rather than assume
that clients have reasoned incorrectly, the aim is to track how this reasoning has
been set up, sometimes deliberately manipulated and how it is sustained. This
means questioning ways of understanding that are ordinarily taken-for-granted.
Hence, the centrality of medicine to understanding personal distress is viewed
as an issue to be explored rather than a fact that predetermines our actions. This
approach, therefore, extends the debate about which therapy is indicated for bor-
derline personality disorder, to whether diagnostic classification is a useful starting
point at all.

PERSONALISING WOMEN’S MISERY

According to the medical model, mental disorder is a fixed and internal prop-
erty of individuals that can be deciphered through tracking causality and interpret-
ing symptoms. Diagnosis, therefore, holds a central place within the practice of
scientific medicine because it represents the mechanism through which (mental)
abnormality can be interpreted and classified (Warner & Wilkins, 2003). Diagnosis,
Women, Borderline Personality Disorder and High Security Mental Hospitals 267

in theory, provides an accepted standard that can be reliably applied to the same
problem by different clinicians. Yet, clinicians continue to disagree about stan-
dards, and categories can be stretched such that similarities between people are
magnified and individual difference disregarded (Brannon, 1999).
Formalised diagnostic systems, such as the Diagnostic and statistical manual
of mental disorders (DSM-IV) (American Psychiatric Association/ APA, 1994), as-
sume that disorders of the mind can be differentiated according to the ways key
symptoms cluster together to form distinct and stable descriptive categories. Be-
cause such systems focus on which symptoms are present, rather than the contexts
in which they arise, the social constitution of mental disorder is seldom explored.
Yet this is crucial if we are to explain differential diagnostic patterns, in respect of
gender for example. Within DSM IV clinicians are warned to:
be cautious not to over diagnose or under diagnose certain personality disorders in females
or in males because of social stereotypes about typical gender roles and behaviour (APA,
1994:632).

Yet, research suggests that such bias frequently affects diagnostic practices
(Brannon, 1999). If this assertion was simply a fabrication of those who have
a political objection to diagnosis then the APA would not, itself, feel the need
to warn practitioners not to succumb to such bias. Men and women’s behaviour
is often judged in very different ways in mental health services. For example, a
study conducted by Warner (1996) found some evidence to suggest that in high
security mental health care women’s behaviour is more likely then men’s behaviour
to be viewed as being pathological. Consideration should be given, therefore, to
those social factors that impact on the decision-making processes that underlie
diagnosis.
This is particularly important with regard to diagnosing borderline personality
disorder because it is a distinctly gendered category. This is in the sense that women
outnumbering men, at a rate of anywhere from 2:1 to 9:1, depending on the sample
under investigation (Becker, 1997). As such, when considering this disorder we
should be careful not to read too much into women’s behaviour and too little into
men’s. Nevertheless, borderline personality disorder does seem to capture some-
thing of the generic female condition. Current descriptions of this disorder em-
phasise affective symptomatology including rage, depression, self-destructiveness
(including suicidality), feelings of emptiness, and emotional lability. It can be ar-
gued that descriptors, such as emotional lability and self-destructiveness, represent
the extreme characteristics of the female role and hence, are more likely to typify
women than men (see Tavris, 1993).
This is not an argument for the biological basis of behaviour. Turning rage
and depression inwards may have less to do with women’s biological inadequacies
and more to do with their social marginalisation and subjugation. We should be
careful, therefore, not to pathologise individuals for what might be better under-
stood as being the result of social inequality and restricted choice. Although men
268 Warner and Wilkins

typically externalise aggression, when they too have their choices restricted this
is frequently accompanied by a significant increase in self-destructive behaviour.
This is evidenced in the marked increase in self-harming and suicidal behaviour
demonstrated by men who are imprisoned (see for example, Wolfersdorf, 2000).
It can be argued, therefore, that the presence of self-destructive behaviour may tell
us as much about the situation as it does about the individual person concerned.
So far we have established that borderline personality disorder is commonly
diagnosed in women. We have suggested that the behaviours associated with this
diagnosis may be indicative of subjugation and powerlessness. It is little wonder,
then, that childhood abuse has been found to be related to the later emergence of
psychiatric symptoms associated with the borderline syndrome. There is some evi-
dence that child sexual abuse is of particular significance (see Brown and Anderson,
1991, Western et al, 1990), and that increased severity, duration and number of
perpetrators differentiates this disorder from others (see Silk et al, 1995; Koerner
and Linehan, 1996). If sexual abuse is an important factor in determining the later
emergence of the borderline syndrome, it is unsurprising that women predomi-
nate in this category as they are more likely to experience this form of abuse than
men are (see for example, Finkelhor, 1994). This may be especially the case for
involuntarily detained female patients.
For example, a review of case note material of all women patients diagnosed
as borderline personality disordered within one British high security mental hos-
pital found that all 16 women reported histories of child sexual abuse (the majority
corroborated); over half the sample reported histories of physical abuse and re-
moval into care; and all could be judged to have suffered from emotional abuse
and neglect (Wilkins and Warner, 2001). Additionally, in an extensive review of
British mental health services for women, the Department of Health (2002) esti-
mated that, for women in high security mental health care at least 70% may have
histories of child sexual abuse and over 90% self-harm. They also note that such
women are more likely than men are to be given the diagnosis of borderline per-
sonality disorder, and that this is the most prevalent diagnostic category for high
security female psychiatric patients. These findings support the North American
research referenced above that has found an association between child sexual abuse
and borderline personality disorder. They are also consistent with the American
Psychiatric Association’s emphasis on self-destructiveness (APA, 1994).
The borderline diagnosis could function as a signpost that invites consider-
ation of the potential impact of negative childhood experiences on such clients.
Yet, when the borderline syndrome is diagnosed the normality of women’s ac-
tions in response to extreme and abnormal events is obscured because symptoms
are divorced from root causes (Linehan, 1993). Diagnosis, ultimately, transforms
these social effects into individual pathology and offers little opportunity to fully
consider the reasons for women’s actions (Akhtar 1995). Insufficient concern may
then be given to the life situations and cultural backgrounds of those who expe-
rience such problems (Lerman, 1996). Additionally, as Maracek (1997) argues,
Women, Borderline Personality Disorder and High Security Mental Hospitals 269

by ignoring the social and interpersonal context to individual misery, diagnostic

systems disguise the way that so-called mental disorders are products of their
particular time and place.
As such, there may be some justification, as Costello (1996) suggests, for
jettisoning diagnostic labels in favour of a more direct concern with the experience
or behaviour that seems to lie at the heart of the patient’s problem. Such an approach
requires a major shift away from medical conceptualisations of disorder (Sperry,
1995; Spitzer, 2000). Parson (1997) argues that women diagnosed as (borderline)
personality disordered need a quite different form of specialised intervention from
other mental health categories. We do not. Rather, we think that most people would
benefit from having their individual experiences of misery understood in a social
context. In this sense, we consider that it is the uniqueness of people’s social
experiences and related effects that inform our approach to treatment, rather than
the specific diagnosis they may be given.
The utility of the borderline diagnosis may be a contentious point. Addition-
ally the ubiquity of childhood abuse may be open to challenge. Indeed, it would be
antithetical to the social constructionist framework adopted in this paper to suggest
that all people diagnosed with borderline personality disorder have been abused
and actively self-harm. However, we do think that for those clinicians who work
with involuntarily detained female clients particular attention should be given to
issues of abuse and self-harm. This means we think these are important questions
to ask of our clients. We do not simply assume childhood abuse is the only reason
for their so-called borderline behaviour. With this is mind, the following sections
elaborate how we think through and work with issues of abuse and self-harm in
relation to involuntarily detained female patients diagnosed with borderline per-
sonality disorder.

MOVING FROM PATHOLOGISATION TO RECOVERY

When patients are identified as the source of all difficulties other people can
absolve themselves of responsibility when things go wrong. At the same time the
“problem person,” feeling attacked and invalidated, may react with aggression or
depression and hence, struggle to take responsibility for the things they can per-
sonally change. The women patients we work with in secure mental health services
often report multiple experiences of having their thoughts and feelings invalidated,
have long been thought of as being “the problem” and present with very low self-
esteem (Warner, 1999). Psychiatric labelling can further contribute to women’s
negative sense of self because the focus is on disorder rather than adaptation. And
as Gergen (1991) argues, the tendency to pathologise can lead to “a spiral of infir-
mity,” which also exaggerates their passivity (Drewery & McKenzie, 1999). This
is the case when clients are viewed as being essentially damaged by virtue of their
biology or their pasts.
270 Warner and Wilkins

Our first step in therapy, then, is to resist the desire to pathologise. As sug-
gested patients may already have a well-developed negative self-image, and pas-
sivity does not enable them to take charge of their lives. Hence, we avoid the
language of deficits, distortions, or dysfunctions because it ultimately devalues
and derogates our clients, and denies their adaptability. We are explicit about our
belief that all clients are capable of recovery—however limited this may be. The
notion of “recovery” may be unfamiliar within North American psychiatric con-
texts. However, it is of increasing relevance within British mental health services.
A recovery model of mental health, first proposed by radical mental health activists
(e.g. Coleman, 1999), has now been partially adopted within mainstream mental
health services. The Department of Health (1999) now advocates for more social
and holistic recovery-based mental health services, rather than services organised
around more restricted medical conceptualisation of mental disorder.
The idea is that mental health is achieved through addressing a range of social,
psychological, medical and environmental factors, some of which will be beyond
the remit of the specific client. A corollary of this is that any mental health ser-
vice that fails to address social and environmental factors will be impoverished.
Recovery is an explicit goal of such services and is defined in a multitude of
ways, depending on the individual recipient of service. This is a markedly dif-
ferent approach to an addiction model of “recovery,” whereby clients are seen as
being permanently “in recovery,” but never recovered (see for example, Narcotics
Anonymous, 1988). A recovery, rather than addiction, model is already focused on
change, rather than pathology. We think this shift in focus is extremely important.
If we believe people can change we build services that encourage people to leave.
If we believe people cannot get better we build services that confirm their disorder
and keep them there.
If we view borderline personality disorder as an unstable description of re-
lationship problems, rather than as an internal and fixed identity we are already
recognising our clients’ capacity to change. This is not to deny that the diagnosis
of borderline personality disorder has long been associated with therapeutic pes-
simism. Rather we suggest that some of this pessimism is rooted in our models of
distress, rather than simply being a function of the individual patient concerned.
Recovery in these terms is about maintaining hope that people can find more help-
ful ways of managing their lives. It is not about suggesting that we can cure all ills.
That, of course, would be naı̈ve and would set our clients up for more experiences
of failure. It is about having specific goals that might be possible to achieve. This
is crucial because it is all too easy for patients and workers in secure services to
lose hope for the future:

It’s perhaps more an existential problem, which is not very medical really. You’ve been in
the system for more than a few years, you know you don’t have the survival skills. You
know you’re getting nothing out of it, and the institution doesn’t provide very much. So
there’s the problems that go with that and you give up. When we first started taking these
women in, and that was before we knew very much at all about abuse issues, the women
Women, Borderline Personality Disorder and High Security Mental Hospitals 271

weren’t going to be in for very long. Well some of those women are still here. Some of them
are getting on for a number of years, for decades. Perhaps it’s a manifestation of having
given up. (male psychiatrist)

Underlying a social recovery model is the idea that hopefulness is engendered

in people when they have a sense of personal control over their life: that they have
some hope they can change some of the things that make them unhappy. One of our
aims in therapy then is to provide a lived experience of a non-abusive relationship,
in which women have a sense of personal control. We view our clients as being
co-authors of their therapy, in that we openly acknowledged that both parties bring
skills and expertise to the therapeutic relationship. Clients have extensive expertise
regarding their life narratives. Conversely, we bring with us considerable expertise
around, for example, understanding the effects and tactics of abuse and the multiple
meanings of self-harm. To deny our knowledge and abilities is to act like abusers
who trick and manipulate.
In this sense, exerting power is not, in itself, unhelpful. It is problematic when
power is enacted, but inequality is never explored. As Kaye (1999) argues therapy
should be about opening up new possibilities and choices rather than strengthening
hierarchical structures that formalise clients as passive recipients of the expert’s
wisdom. Power is not just a function of the relationship between client and therapist,
but is also indicative of the particular social and material environment (Riikonen &
Vataja, 1999). Therapist may be largely more powerful than their clients, although
particularly in secure care clients can act in immediately more powerful ways that
frighten us. However power is used, or abused, we try and explore how it works
in order to promote collaboration. One way we do this is to make what we think
explicit.
This means that we do not pretend an objectivism within the therapeutic
relationship that cannot be sustained (Byrne & McCarthy, 1999). Rather, it entails
a “situated honesty” (Warner, 2001, 2003b) whereby we share our thoughts, and
sometimes our feelings. For example, with respect of self-harm we might say
“I think that self-harm can be an effective coping strategy in some situations. I
accept you have a good reason, but I still worry about you when you do it.” etc.
Sharing opinion is much more effective than sharing “self,” This is not permitted
within secure services. More importantly, there is always a limit to self-disclosure,
although few limits on sharing opinion. Sharing thoughts is a way of deconstructing
the therapist’s power. Being a blank screen is extremely controlling. This is why
working with so-called elective mutes can be so frustrating.
Collaboration is further strengthened through activities that concretise the
active nature of the partnership. For example, we identify together issues to be
addressed and build in dates for active review. It is this attention to the building
and sustaining of therapeutic relationships that we see as being central to the task of
therapy. Psychotherapy outcome studies consistently demonstrate that successful
therapies mostly correlate with the quality of the interpersonal relationship, rather
272 Warner and Wilkins

than the methods used, or the length of training of the professionals involved (e.g.
Riikonen & Vataja, 1999). It is very important then that therapists consider the
impact their style of communication has on their clients.
Accusatory styles of communication invoke feelings of anger, shame and
despair. If we too quickly act in ways that shame our clients we contribute to the
guilt frequently occasioned through early experiences of abuse. Inducing feelings
of alienation, resentment and anger may also ultimately result in increasing the
risk of violence to self or others (Law, 1999). Therapist may then make too much
of their clients’ anger and hostility, even though other emotions including sadness,
anxiety, panic, humiliation, and fear, as well as shame and guilt are present for
“borderline” women in great measure (Linehan, 1993). Hence, when we make
interpretations we try to frame these clearly, but as possibilities, rather than deliver
them as accusations, in a confrontational style (Wile, 1984). We also try to engage
with those feelings that anger often masks.
This is why the therapy we do is “visible.” It is about actively exploring the
operations of power in therapeutic relationships, as well as past and current ones.
This is why we consider the process of therapy to be as important as the content
of which we speak. In this sense, our approach has much in common with psy-
chodynamic approaches to therapy (e.g. Malan, 1979). However, where we differ
is in respect of the values we place on particular issues. We do not presume that
early familial relationships are always the most significant in determining future
functioning, nor do we impose a template for adult relationships or behaviour. For
example, we think that heterosexuality, homosexuality and celibacy all have their
merits. Additionally we talk about coping strategies rather than defence mecha-
nisms. Whilst we avoid predetermining which relationships are important for our
clients, the issue of abuse frequently emerges as being significant, particularly in
terms of understanding women’s current coping strategies. Therapy, then, is often
directed to understanding past experiences of abuse and making sense of current
self-harming behaviour.

UNDERSTANDING THE TACTICS OF ABUSE

In order to understand current “borderline” behaviour we think it is useful to

explore past, as well as current circumstances. As argued, behaviour is likely to
be more meaningful when we relate it to a social context, rather than too quickly
dismiss it as “borderline” (Landecker, 1992). As noted, in this context past histories
of abuse are frequently significant factors in making sense of current behaviour.
As Akhtar (1995) suggests, traumatic childhood experiences are indicated through
the ways adults describe their inner worlds and enact their lives. And as Becker
(1997:85) argues, “understanding the past provides clues deciphering how and
why the present is being approached and shaped the way it is.” Our aim in talking
about past abuse is not to produce an ultimate story of causation, but to enable
Women, Borderline Personality Disorder and High Security Mental Hospitals 273

exploration of the links between current versions of self and remembered past
versions of self (Warner, 2001; 2003b).
Like psychodynamic therapists, we are more concerned with how our clients
remember their experiences of abuse, than with establishing what in fact occurred.
From a social constructionist perspective the truth about what is remembered can
always be revised and contested. As we can seldom prove or disprove the detailed
past, it seems much more useful therapeutically to explore how and why it may
be remembered as it is. Challenging the veracity of women’s accounts at onset
is unhelpful because it invites them to close down. Indeed, various studies (for
example, Kendall-Tackett et al, 1993) have highlighted the significance placed on
being believed in determining future recovery from experiences of child sexual
abuse. This continues to be a key concern into adulthood. As one female patient
explained:

Being believed is the main issue. That’s the thing. What I want out of it is to have people
believing me. You don’t know what you can believe when you’ve been abused.

Whilst sometimes patients mislead and their stories change, we believe that
any story is told for a reason. In order to encourage the story to unfold we remain
“agnostic” over the truth (Warner, 2001, 2003b) so that we maximise the opportu-
nities for making sense of how our clients understand their past and present lives.
Hence, we are open to believing our clients because we do not have as a key aim
disproving what they say. In secure care it is especially important to be open to be-
lieving because “borderline” women in these systems too often have their personal
stories of abuse dismissed or denied:

The fundamental bit, of cause, is believing. Because in the ultimate forensic institutions the
message that people are given is that these patients are dangerous and lie, so when someone
tells you anything you assume they’re lying to begin with. So if they tell you about their
early abuse you have to question the validity of that. (female clinical psychologist)

In therapy we encourage our clients to tell their story without immediately

identify and challenging any inconsistencies. We then use this as a basis for begin-
ning to elaborate how their beliefs and feelings about self and others may have been
shaped in their particular life. We recognise that individual experience of abuse
are never simply private, but are influenced by wider cultural and social forces. As
such, we attend to social factors beyond the immediate individual experience of
abuse. For example, many tales of trauma, abuse and victimisation serve to perpet-
uate images of women as weak, passive, and asexual and images of men as sexually
driven, unstoppable, and potentially dangerous (Reavey and Warner, 2001). Such
accounts strip women of self-determination and agency (Kendall, 1993) because
they do not show where women take some control of their bodies and their lives.
We hope to encourage clients to recognise and reclaim their own sense
of personal, albeit provisional agency through finding different meanings for
past events (Kaye, 1999). In this way we aim to transform general stories about
274 Warner and Wilkins

powerlessness into specific accounts of how powerlessness was sometimes sub-

verted. And through these different meanings, we hope clients find a different sense
of self. For example, we hope clients feel less guilt and helplessness by being spe-
cific about their attributions (as a cognitive model would suggest): “I was not to
blame for the abuse I endured. I did find ways to survive and protect myself.” By ex-
ploring different versions of the past we aim to talk through the feelings women ex-
press, rather than simply correct them (as some forms of cognitive therapy might).
For example, when women express feelings of guilt about childhood abuse we
explore how guilt is used to ensure children’s silence and acquiescence, and hence
why there are practical reasons they feel guilty. It is not their inability to process
information that means they feel guilty, but rather their ability to understand has
been manipulated (see Warner, 2000; 2001; 2003b). This is why we see problems as
social, rather than internal, and attend to the ways language structures the landscape
of private grief. Again this allows for the operations of power to be named, tracked,
explored and resisted. As Law (1999) argues, when experiences are talked about,
they become visible and contestable, rather than remaining accepted and unnoticed.
We are also mindful that there are multiple ways in which women are sub-
jugated through their different experiences of race, ability, gender and sexuality.
Another therapeutic aim is to enable clients to explore the specific meanings such
identifications have for them, at different points in time and in different contexts.
For example, being female in mixed gender secure care can be hazardous because
women are incarcerated with some men who are sexually predatory. As such, we do
not think the goal of therapy is to enable women to learn to trust men. Sometimes
some men (and some women) should not be trusted:
They don’t trust men. I’ve heard more trust women. They won’t go on wards with men if
they can avoid it [because] they don’t feel comfortable. (female patient)

We validate women’s attempts to keep themselves safe. We explore when

and how they feel unsafe in the present and make links with the experiences they
remember from the past. We do this by identifying and naming the tactics used to
ensure their particular silence and acquiescence when abused, and explore the con-
nections with their current feelings, beliefs and behaviour. For example, women
may have learnt that sex made them a “special” child and so are vulnerable to those
who might manipulate them into adult sex through making sex the prerequisite
for recognition and “special” care (see Warner, 2000). Additionally, we talk about
how women coped with difficult experiences in the past and how they continue to
cope now.

MAKING THE EFFECTS OF ABUSE VISIBLE

When children are subject to repetitive abuse they must find ways of with-
standing the negative effects on their sense of self. Children may cope by distancing
themselves during the abuse through denial, distraction, and dissociation (Warner,
Women, Borderline Personality Disorder and High Security Mental Hospitals 275

2003b). They may cope with their subsequent feelings of powerlessness by self-
harming. Any of these strategies of self-preservation can become generalised and
endure into adulthood (see van der Kolk et al, 1987; van der Kolk et al, 1991). Dis-
sociation can result in people hearing the voices of their abusers long after the abuse
has ceased or being subject to intrusive thoughts and images from the past (Warner,
2000). Kroll (1993) suggests that “post traumatic stress disorder” may provide a
better diagnostic conceptualisation of such women because it does not stigmatise
in the same way the “borderline” description does, specifically because it makes
explicit the connection between symptoms and situational causes. However, as
already argued, our concern is with the connections, not with categorisations.
Hence, we are concerned with not just what women survive, but how they sur-
vive. For example, if women have utilised dissociation as a coping strategy during
abuse, they may have very few detailed memories of such experiences. Sometimes
it helps women to understand how memory works and why they may feel their life
narrative is so disjointed and disconnected. Because of gaps in memory women’s
characteristic coping strategies such as dissociation and self-harm may provide
the bridge between past and present versions of reality (LeFevre, 1996). Hence,
we try and make sense of the voices women sometimes hear and the visions they
sometimes see, rather than try and “disprove” their existence. We explore how
self-harm works for them, rather than simply assume it is pathological and should
be stopped. For example, seemingly unendurable psychological tension can be
rapidly relieved by self-injurious behaviour such as skin cutting (Favazza,1987).
Dissociative experiences often accompany such attempts at self-injury (Waites,
1993). As one nurse explained:
I think, sometimes, they just put up a front: that they don’t have any feelings, that they can
do all these things. They can just block off the pain. They can do anything to themselves,
you know, put their arm in boiling water or whatever and it won’t hurt them. (female nurse)

In contrast to other therapeutic approaches to working with people who are

diagnosed as borderline personality disordered we do not expect our clients to stop
self-harming before we start therapy. We may hope that an end result of therapy is
that people have developed alternative, less obviously damaging, coping strategies.
However, we do not assume that all our clients will stop cutting and harming
themselves. Women in high security mental health care may have spent years
self-harming, and it would be naı̈ve to assume that this behaviour would entirely
disappear after therapy, let alone before therapy began. Some radical mental health
activists have proposed a model of “safe” cutting (Pembroke, 1994; LeFevre, 1996).
According to this model self-harm is a legitimate coping strategy that some people
will always use. When this is the case, sterile razor blades etc should be provided
in order to minimise the long term damage occasioned by such practices. This
approach is far from being adopted in statutory high secure care. However, there
is increasing recognition that self-harm must be worked with rather than simply
restricted, not least because restriction frequently fails.
276 Warner and Wilkins

Additionally, if all we do is attempt to control women’s self-harm, we paradox-

ically undermine their self-efficacy, and reinforce the need for self-harm. Women,
diagnosed with borderline personality disorder, may have had a lifetime of being
abused, discredited, and dismissed and are all too ready to internalise feelings of
failure and lack of self-efficacy. If the surface action remains the focus this can
engender punitive and dismissive responses on the part of professionals, who feel
manipulated, affronted, disappointed and upset. Self-harm may be experienced as
a challenge to the authority and experience of the therapist, when it is often the
last resort of the least powerful (Becker, 1997). And as Linehan (1993:17) argues,
the interpretation of their behaviour as manipulative may be ultimately a “major
source of their feelings of invalidation and of being misunderstood.”
It is important, then, to explore the positive effects of self-injurious behaviour
rather than simply focus on the negative. Our aim is to enable women to recognise
their strength and creativity, so that they can more deliberately mobilise their
own survival strategies and build on these to develop new skills. In our clinical
experience self-harming behaviour reduces when people start to value themselves
and experience a sense of agency over their lives. This is why it is helpful to look
beyond the diagnostic category to the underlying issues that bring meaning to
women’s symptomatic behaviour.

SOME CONCLUSIONS

In secure mental health services issues of abuse and self-harm are key factors
in understanding and working with women who are diagnosed with borderline
personality disorder. We do not suggest that such issues are always and inevitably
key factors for all people who receive this diagnosis nor that abuse and self-harm
will be present in equal measure for all compulsorily detained female patients.
However, we do think consideration should be given to the social foundations of
individual distress. Diagnosis can impede this process because it too readily in-
vites us to withdraw from a social model of misery. “Borderline” too often is a
stigmatising description that papers over our own feelings of hopelessness. This
is why we think language is so important, why we avoid categorisation, and why
we work with the issues that underlie behaviour. Adopting less medical, and more
social, ways of representing women and their problems extends the focus of our
concern and when we extend our concern we also extend the possibilities of finding
solutions.

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