Talking to adolescents about emerging borderline personality disorder: a discourse analysis of clinician and client perspectives

Abstract

This research examines whether Child and Adolescent Mental Health Service (CAMHS) clinicians talk to their adolescent clients about emerging borderline personality disorder (BPD) and how this talk is framed. While academic literature presents the diagnosis of BPD as viable in adolescence and ‘good enough’ for clinical uptake, it is not clear how clinicians work with this diagnosis in adolescence.

This thesis presents a discursive analysis of 23 clinician and 8 adolescent interviews across CAMHS community settings and an adolescent psychiatric unit. Analysis incorporated an examination of both text and context; identifying the language used to talk about BPD and diagnosis in psychiatric settings, according to both clinicians and adolescents.

Findings indicate that practices of disclosure to adolescents are highly context dependent. While community clinicians were allowed to talk about BPD with adolescents in a ‘careful and cautious’ manner, inpatient clinicians were governed by a hierarchy which discouraged any conversations about BPD. This prohibition was accompanied by a reliance upon ‘borderline talk;’ a shorthand dialogue used by nurses informally to communicate borderline traits and associated expectations.

Clinicians at both sites positioned the diagnosis as flawed, considering the connotations of permanency as discordant with adolescent personality trajectories and worrying about potential stigma and service rejection. In the absence of a robust diagnosis, clinicians were forced to construct alternative ways of working with or around this diagnosis. Thus the BPD diagnosis was tempered, with clinicians overwhelmingly advocating for the use of semantic strategies such as hedges (i.e. ‘emerging’ and ‘traits’) in order to ‘soften’ the diagnosis and maintain hopefulness.

Adolescents were mainly unaware of their diagnosis of emerging BPD, relying instead upon other diagnoses to inform identity work. Diagnosis as a construct was universally depicted by adolescents as helpful, reflecting a strong alliance with medical discourses of understanding and treating. Being diagnosed on the other hand was complicated. At times it assisted identity work and delivered on expectations of providing understanding. For other adolescents it muddied and confused their identity work, serving to disconnect their experiences from those tools of description which were made available to them.

This thesis serves to unsettle taken for granted assumptions regarding the privileging of diagnostic information for clinicians (or non-disclosure), finding that adolescents are likely and entitled to arrive at their own conclusions regarding diagnostic fit and usefulness.

Clinical recommendations include the questioning of hedges and borderline talk. While the function of these tools is clear, reliance upon this language may serve to perpetuate the overuse of the term borderline and maintain ‘shorthand’ and stereotypical understandings of a complex diagnosis.