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.

Categories: Ethics, Personality, MentalHealth