Unruly Affect: Disciplinary Technologies of the Self in Therapy for Borderline Personality Disorder

Lynsay Hodges explores how a current intervention for Borderline Personality Disorder (BPD) seeks to regulate and discipline what they term, the ‘unruly affect’.

Content warning: self-injury.

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is characterised in diagnostic literature such as the DSM-V as a condition of being ‘unstable’. People diagnosed with BPD coalesce around symptoms such as tumultuous relationships predicated on a fear of abandonment, identity disturbance, impulsive behaviour, self-harm, suicide attempts (American Psychiatric Association 2013, 766–767), and what I call “unruly affect”.

Image by Taylor Deas-Melesh (Unsplashed)

Unstable moods and difficulties regulating emotions are frequently highlighted as the biggest concern for clinicians (see, for example, Glenn and Klonsky 2009 and Baer et al. 2012). We live in a society that has treasured rationality since the Enlightenment, with Descarte’s infamous proclamation of “I think therefore I am”. The so-called passions have been marginalised ever since, along with the people with whom they are associated, including those in mental distress. Unruly affect, then, does not currently fit in with a neoliberal society that valourises productivity and rational behaviour or feeling. Unruly emotions must be controlled for one to fully exist as a citizen in such states.

Psychiatrists and psychologists—or “psy clinicians”—are seeking ways to tackle BPD. I use this word “tackle” purposefully; it is an aggressive word for aggressive behaviour. It is not news to say that psy clinicians often have disdain for—and sometimes outright hatred of—people with BPD (see, Harned et al 2006 and Veysey 2014). This is compounded by misogyny: up to 75% of people with a BPD diagnosis identify as women (Amerio et al., 2023). The fact so many of those diagnosed with the disorder are victims of child abuse and sexual violence has led feminist scholars to argue that the diagnosis itself pathologises a reasonable response to trauma (Show and Proctor 2005 and Ussher, 2011).

It is also not a new assertion to say that the psychological sciences are actively oppressive. French philosopher and historian Michel Foucault made this point in the 20th century. In particular, Foucault shows throughout his work how disciplinary power operates within ‘psy’ discourses, regimes, and institutions to promote “docile bodies” that befit the social and cultural norms we inhabit. When power over the individual is applied in this way en masse, one can speak of biopolitics: the control of a population to ensure it makes live, for the sake of productivity and restricting ‘abnormality’.

This essay applies Foucault’s critique to a therapeutic intervention for BPD: Systems Training for Emotional Predictability and Problem Solving (STEPPS). It shows how this therapy is constituted by an internalisation of the disciplinary power enacted by the psychiatric regimes we, as service users, navigate. Through the example of STEPPS, a programme that I myself have taken part in, I will show that the ‘unruly affects’ of BPD become the target of ‘power-knowledge’ (Foucault, 2020c) in order to subject them (literally form them as “subjects”) and subjugate them. I argue that this then becomes internalised by those undertaking the therapy as a “technology of the self” (Foucault 2020b, 225): an inward-focused regime that helps one to construct their ways of being to better approach a state of perfection. Through these technologies of the self, the person with a BPD diagnosis learns to render themselves docile. I take a political stance on this, arguing that it makes them more palatable to norms and more productive under capitalism. The result can be a failure, creating stigmatising and oppressive treatment of those trying to live up to standards that are impossible to achieve.

The Treatment of BPD in Mental Health Services: The Rationale Behind STEPPS

STEPPS is an intervention specifically targeting BPD that takes its cues from cognitive behavioural therapy (CBT). Comprised of twenty weekly, two-hour long sessions, it operates more like a course than a traditional talking therapy, made up of a “class” of individuals diagnosed with BPD who are guided through a series of worksheets by a small team of psy clinicians. We can already see the similarities between the set-up of STEPPS and other disciplinary institutions (and their relationship dynamics), such as schools. 

The “course” content of STEPPS overwhelmingly focuses on the management of intense emotional states, with the aim being greater emotional regulation and a reduction in self-injurious behaviour. Towards the end of the programme there are “lessons” on general maintenance of physical and psychological wellbeing.

Although the STEPPS programme is not supposed to replace individual therapy (Blum et al., 2008), my experience contradicted this. In an overwhelmed and underfunded NHS trust, the STEPPS programme is a relatively cost-efficient solution to a “problem” group of patients who make up a large portion of the service-user population. As such, STEPPS was the first and, except in exceptional circumstances, the only intervention available to those with a BPD diagnosis in my local community mental health trust. This meant that there was little opportunity for most service users to discuss their experiences outside of the confines of the course material. Filling out the “emotional intensity continuum”, which rates on a scale of 1–5 the intensity of an emotional outburst as well as describes its quality (in terms of feelings, physiological responses, thought patterns, and resultant behaviours), was one of the only ways we could discuss events in our lives. There was little room to discuss any underlying trauma, which can be a large part of the aetiology of BPD symptoms. Instead, the focus remained solely on the intensity—the unruliness—of emotional episodes and behaviour deemed unhealthy and problematic.

The end goal of STEPPS is the discharge of patients out of secondary care, transferring their monitoring to a general practitioner. The idea is that the “skills” taught by the programme will allow the diagnosed individual to self-manage their condition, only needing professional intervention for issues relating to medication. This fits in well with an NHS on its knees, with 1.2 million people on the waiting list for mental health treatment in 2023 (BMA 2024).

Self-Examination and Self-Discipline: STEPPS Techniques as Disciplinary Technologies of the Self

Foucault describes how the disciplinary power of both the medical/psy examination and the intervention techniques lead to the creation of a docile body, one that is productive and in keeping with societal norms. The examination allows for the formation of a power-knowledge nexus that reveals aspects of a person’s subjectivity to the examiner, partly in order to root out deviance from established social norms. The discussion of the emotional intensity continuums in STEPPS offers up the experiences of the service user for scrutiny by their peers and the psy clinicians (Rose, n.d.). This is used to ascertain a more comprehensive picture of who they are and to account for any “progress” made, something that is measured each week via a series of questionnaires.

The STEPPS programme can be seen as a disciplinary programme par excellence. It encourages the constant examination of the self and intervenes in one’s behaviours and thought patterns in order to encourage “better”, more “adaptive” coping mechanisms. From picking apart “thought distortions” (such as catastrophisation) to using distractions deemed to be suitable alternatives to those considered self-injurious by the clinicians, the mind and body of the person with a BPD diagnosis is modified to curtail unruly affects and their wider consequences.

It is not enough, however, for the clinicians to examine and intervene. STEPPS is a training course that uses disciplinary tactics as technologies of the self. Foucault describes how these technologies

permit individuals to effect by their own means, or with the help of others, a certain number of operations on their own bodies and souls, thoughts, conduct, and way of being, so as to transform themselves in order to attain a certain state of happiness, purity, wisdom, perfection, or immortality (Foucault 2020, 225).

However, the STEPPS programme doesn’t necessarily aim for these positive states. It seeks to temper the excesses of unruly affects, curtailing problematic behaviour which would perhaps require further intervention by services that do not want to offer further support for a multitude of reasons, such as cost and the perceived “difficulty” of those with a BPD diagnosis. It is here that we can see how these technologies of the self are also technologies of disciplinary power, which Foucault describes as those “which determine the conduct of individuals and submit them to certain ends or domination, an objectivizing of the subject” (Foucault 2020, 225).

STEPPS inculcates in the service user a disciplinary technology of the self, one which aims to temper the individual’s conduct to allow them to reach a point of being discharged from services and prevent them from coming back. It is an intervention which, through teaching ‘better’ emotional regulation, aims to make service users conform to the norms of society that deems intense emotions as defunctive.  Once this has been achieved, the individual gains better access to society, which in turn allows them to become productive.

Problematising Emotional Regulation

While it is true that many people with a BPD diagnosis engage in self-injurious behaviour as a result of their intense emotions, trying to aid them to not carry out these behaviours is not the issue here. Rather, the issue is the turning of something as personal as an emotional response into something that needs to be controlled in order to conform to an ableist society’s normalised model of what emotions are appropriate and to what degree.

It should be noted that, historically and contemporarily, emotional expression has been tied to those marginalised in society—women, people of colour, and queer people, for example—in order to exclude them from a liberal society based on rationality and objectivity (which the social sciences have taught us is a fallacious notion no matter how much it persists) (Blackman, 2008). This means that those who genuinely do exhibit affects deemed unruly are also, by their nature, excluded from society unless they internalise the disciplinary messaging of programmes such as STEPPS, which aim to transform the self into something approximating the norm.

The bind, however, is that this is simply is not feasible for many of us with a BPD diagnosis. This is especially considering that 91% of these people will have at least one additional psychiatric diagnosis that complicates the matter (Blum et al., 2002: 302). A norm is based on the statistical idea of standard deviation (The BMJ, 2021), meaning there will always be some that exceed the norm in terms of the intensity of their emotions. For these people—and those with a BPD diagnosis are within this category—trying to at least approximate the norm is an exercise in futility. However, programmes such as STEPPS inculcate within them that they are somehow defective if they do not exhibit more emotional regulation and “resilience”—an insulting word to use when many are survivors of trauma that is incomprehensible unless one has experienced something similar.

STEPPS, and the notion of encouraging emotional regulation more widely, implicitly suggests that, unless one consistently self-examines and disciplines their behaviours and thought patterns in order to meet an unachievable norm, it is feasible to continue to exclude these people from society in some way. It is inherently sanist; that is, oppressive against Mad[1] people. Strive as we might, those of us with a BPD diagnosis will always find ourselves lacking in the eyes of the normalised other, and so the underlying message is that we deserve to be treated negatively because we aren’t trying hard enough to conform. This is accompanied with a discharge at the end of the STEPPS programme. Services use the discharge to avoid providing further care within the community mental health trust, despite researchers explicitly stating STEPPS should be combined with other therapeutic interventions. Become the norm, become a docile producer of profit under capitalism, or be found wanting: that is the situation created by such programmes.

[1] I use this term as a reclamation as per the Mad Pride movement. I am Mad and I find power in taking this word back from those who would denigrate me for my Madness. This is becoming more and more common with those with diagnosed and undiagnosed mental illnesses, as well as in academic literature that critiques psychiatry and psychology.

About the Author

Lynsay Hodges (@lynsayhodges on Twitter) is an independent scholar and writer currently looking for PhD opportunities. Their research interests are within the field of emotion, Madness, surviving sexual violence, and disability.

References

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