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  • Writer's pictureCrone

Caught in the wood (where are the trees??)

...this is where it gets... very bad... and too long...

Section II

To start, I refer you an ’Introduction to Psychology’ lecture presented by psychologist Paul Bloom to his students at Yale and freely available on YouTube. At 47:41 Bloom, a highly respected academic, describes those with BPD as ‘just awful to be with.. Just, awful.’ In his view, ‘some personalities are just so bad that they veer off into mental illness.’ To be fair, Bloom may be describing how the terms are used, rather than attributing the ‘awfulness’ to people, but it’s hard, as one who has BPD, not to feel that this description is offensive. And he certainly does little to distance himself from this description.

Bloom’s seemingly negative assessment is not an isolated case. Research into the attitudes of psychiatrists has consistently demonstrated a ‘dislike’ of those with personality disorders, seeing them as manipulative, attention-seeking and generally bad, rather than mad or sad. Lewis and Appleby, who conducted an early survey, suggest that the idea that BPD is not seen as an illness condition could lead to a lack of sympathy and to blame because of judgments that the patient’s actions are under their control. Zacher? Relate the view of a past chairman of the psychiatry department at New York University, ‘borderliners are the patients you think of as PIAs—pains in the ass’.

It seems likely, then, that there is the potential for prejudice and thus the potential for epistemic injustice. This operates in addition to the more common potential for epistemic injustice in medical - and especially psychiatric - situations, where the patient’s testimony may be deemed less important than that of the expert CITE

However, there is also the possibility that a BPD patient’s testimony will not be trustworthy. Firstly, she may, indeed, be manipulative and mendacious: some people are and some BPD patients surely also are. But, importantly, her testimony may lack competency and/or sincerity for reasons that are not blameworthy. There are several possible causes:

1 great sensitivity (described often as ‘skinlessness’) - the patient may be hyper-reactive to slight cues related to threat, dislike, distrust, which may provoke anger, feelings of betrayal, fear, grief or self-censorship

2 feelings of distrust - which may lead to the patient cutting herself off from hermeneutical resources that could help her

3 changeable - with different reactions, interests and values at different times

4 finding difficulty in explaining or articulating feelings or reasons for feelings, which may be related to a lack of hermeneutical resources

5 feelings of inauthenticity - the patient may then self-censor, which Carel and Kidd describe as ‘another form of epistemic injustice in which the negative stereotyping is internalized by the patient herself, leading her to downgrade her own testimony’.

All five are important, and inter-related, but due to space constraints I will focus on (3) and (4) which , I believe, offer especially fertile terrain for future work. I believe that there is a ‘thinness’ to the current understanding of BPD. I will use my own phenomenological experience as an albeit inadequate individual sample to consider how that understanding might be thickened.

In the following discussion, I will draw together the two issues, the painful sense of incoherence and the chameleon-like changeability, as I feel they are better understood as two faces of a similar concern. To explore this territory, I will rely upon the phenomenological literature. This account does not claim to be causally explanatory, but instead seeks to offer a perspective that helps to communicate certain hard to articulate experiences.

Matthew Ratcliffe, in writing of depression, suggests that in considering the depressed state, the concept of ‘existential feelings’ is helpful:

Existential feelings have a distinctive phenomenological role; they constitute a variable sense of the possibilities that the world incorporates. Depression… involves a change in the kinds of possibility that are experienced as integral to the world and, with it, a change in the structure of one’s overall relationship with the world. RATCLIFFE DEPRESSION

He is building on the work of Martin Heidegger, specifically the idea of ‘ground’ or ‘basic’ moods. For instance:

the ground mood of anxiety [ Angst ] is described as involving a radical alteration in how one finds oneself in the world, amounting to a complete loss of practical significance. It is not just that however many entities cease to be significant. Rather, the possibility of encountering anything as significant in that way is altogether gone from the world: … The world is experienced as a realm in which one can no longer engage with things in an effortless, habitual, unreflective way.

This helps me, as one diagnosed with BPD, to articulate the experience of being ‘different people’ at different times.

I am, as it were, thrown into a world that presents itself to me in very different ways: on some occasions, everything isn’t just ‘ready-to-hand’, it is in my hand and I am acting - this is an impulsive, reckless state with powerful feelings of agency; on other occasions nothing at all is ready-to-hand, all is devoid of purpose - this is depression; at others still, the world is glittering with salience - which may carry a weight of nostalgia or the lightness of transcendence - here I may be tearful and compassionate or excited and generous. All of these states are intractable to reasoning. Thinking and cognition, it seems, are not the cause of the mood and nor can they impact it. The mood is primary - and it instantiate a particular and distinct sense of who I am, what I can and can’t do, what I do and do not value and so on.

This presents a reason for being seen as untrustworthy: if asked ‘what do you want in your life?’ I may have drastically different answers at different times with no coherent explanation for the alteration. Further, if asked why I want or feel this or that, I may find it impossible to give a coherent account. This experience is clearly articulated in a description from ESSAY IN RATCLIFFE BOOK concerning a man with BPD:

as intentionality somehow incapable of being articulated. He experiences himself and others as blurred and fragmented, which provokes excruciating feelings of incoherence, emptiness, uncertainty, and inauthenticity.

In response to such questioning, is the patient to say, ‘It is something about the amount of Tryptophan I have metabolised, the particular angle of the sunlight at this time of year and the average hours of sleep I have managed over the past week as well as an infinite number of other causes related to my genes and upbringing as well as what has happened to me recently that leads me to see the world in this way’? Having over the past years investigated (too) deeply the machinations of the mind, I now experience the painful awareness that much of what is presented to my consciousness evolved in the ‘black box’ of the unconscious, is influenced by unrecognised cues, a half- or totally-forgotten past, the neurochemistry of the brain. I am aware of my thoughts and feelings as being the outcome of complex algorithms that are utterly hidden.

Such a case, incidentally, is made regarding ‘normal’ experience, by the likes of Robert Sapolsky, Michael J. Spivey, Timothy Wilson and others. However, it seems that in ‘normal’ experiences there is a sense of ownership certainly regarding the contents of consciousness (decisions, beliefs and so on). Imagine that someone asks you why you helped a stranger when you passed a bakery. You will not say, ‘Because the smell of cinnamon rolls made me happy’, although that will likely have influenced your decision to help. You say, rather, ‘Because I saw that she needed help’ and you will feel a happy ‘fit’ between the reasons you gave and the action you took.

For me, however, explanations often feel inadequate, inaccurate. They ‘feel’ like a confabulation. As I acknowledge this feeling of wrongness, I am aware of being in a way duplicitous - and may give off unconscious cues to that effect. This does nothing to improve my image as sincere. Or, I could admit that I simply don’t know, admit that those reasons don’t communicate the real reasons. In which case, my capability for credibility is deflated.

It is also the case, that the sense of identity (if defined by beliefs, desires and so on) is often blind to the existence of alternative manifestations of identity in different mood states. It will become clear, in the next section, that a relationship of epistemic trust is required to assist the patient in removing, to some extent, the blinkers, enabling her to appreciate that she has felt and believed otherwise at other times, and also allowing her a means to cope with the disconnect between feelings and reasons.

However, the possible prejudice, the inexplicability, the changeability - added to the difficulty of emotional regulation and the frustration of not being heard, understood or coherent and faced with someone who the BPD patient may not trust - makes the possibility of developing epistemic trust, and thus the environment for epistemic justice, very challenging.

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