Rebecca J. Lester “Brokering Authenticity”

Lester, Rebecca J. 2009. Brokering Authenticity: Borderline Personality Disorder and the Ethics of Care in an American Eating Disorder Clinic. Current Antrhopology 50(3): 281-302.

Managed care is first and foremost an economic model; a system of organizing and rationing health care services within a capitalist system where market forces determine both the cost and value of those services. Built on a rational-choice model of human action with profitability as the ultimate good, managed care is predicated on the stan-dardization of a product (health care) across domains, a reg-ulation of the provision of that product, and a rationing of the supply of the product in order to maximize economic profit and minimize loss (Baily 2003; Goldman 1995; Peterson 1998). To do this, managed care organizations (MCOs), such as Blue Cross, Aetna, United Healthcare, and so forth, con-tract with hospitals and providers to offer services to sub-scribers at reduced costs—what Donald (2001) calls “the Wal-Marting of American psychiatry.” (282)

How, then, do clinicians navigate this minefield of managed care and still feel ethical about what they do? (282)

It is clear, then, that the vast majority of clinicians view managed care as the enemy and perhaps almost as harmful to the client’s health as the eating disorder itself (see also Robins 2001; Ware et al. 2000). How then do eating disorder clinicians function within such a system? (284)

Borderline talk at Cedar Grove is a mode of everyday dis-course among clinicians that invokes BPD to shorthand clus-ters of behavioral and interpersonal concerns. It takes a number of forms. It can be explanatory, accounting for a client’s behavior (“She’s really borderline. She can’t handle that kind of feedback from her peers without going into crisis”). It can be cautionary, as a way of preparing another clinician for an encounter (“Watch out! She’s in full borderline mode to-day!”). It can also become a way for therapists to communicate to each other their personal struggles or even burn out (like the Dementors comment). (285)

The standard managed care view is very different from Cedar Grove’s. In synergy with biomedical psychiatry and cognitive-behavioral approaches (which enable controlled outcomes research and, therefore, lend themselves to cost-benefit analyses in ways psychodynamic approaches do not), managed care tends to figure these illnesses as episodic

cognitive-behavioral dysfunctions that are essentially resolved once the symptoms abate (Wiseman et al 2001). From this perspective, unlearning an eating disorder rests primarily on interventions targeting the specific behaviors involved (food rituals, caloric restriction, purging). The underlying causes and ongoing functions of an eating disorder are not a focus of concern, and issues such as “voice” or “sense of self” are deemed irrelevant. Managed care rests on a rational choice model that presumes people act out of a desire for self-preservation. (286)

“Psychodynamic” is a somewhat generic term that can include a number of different schools of thought, but we can rea-sonably characterize as “psychodynamic” those approaches that entail the following core set of assumptions about human behavior, human motivation, and psychiatric distress: (1) Hu-man behavior is meaningful. This is thought to be true even when the meaning of the behavior is not readily apparent to the individual, the clinician, or others; (2) The meanings of human behavior derive from an interaction between an in-dividual’s life experiences and current social context; (3) The meanings of behavior are closely entangled with an individ-ual’s cognitive and emotional processes, which tend to or-ganize themselves in functional response to an individual’s social and interpersonal environments over time; (4) Indi-viduals themselves may not be aware of the meanings of their behaviors or the substrates of emotion and cognition that motivate them and can even be perplexed or distressed by them; and (5) Therapists and other mental health profes-sionals are specially trained to help individuals uncover the meanings of their behaviors (why they do what they do) or the origins of distress (why they think what they think, or why they feel what they feel). (288)

[…] the idea that mental health is characterized by the development and solidification of the “self” as a seat of largely independent thought, motivation, and action is central to all such models. Specifically, the notion that a healthy self is a “true” self forms the core of the psychodynamic approach. Authenticity, in its epistemic sense, then, is viewed as necessary for the achievement of healthy autonomy. (288-289)

The managed care approach to health care rests on propositions that sit uneasily with those central to the psychody-namic approach. Specifically, the managed care model is built on a notion of autonomy as entailing procedural, versus ep-istemic, authenticity. In this view, authenticity involves the development of capacities to act in accordance with the values and ideals one endorses. Here, authenticity refers more to a consistency of action within a moral system rather than an expression of intrinsic, essential self. Authenticity in this sense involves bringing a subject’s actions in line with the ideolog-ical commitments she espouses. To act authentically means to behave in a way that is consistent with these values. (289)

Contrary to managed care’s rational choice assumption that an individual’s prime directive is self-preservation, the psychodynamic perspective recognizes that mental illness often entails self-destructive intention (e.g., su-icidal gestures, poor self-care, social isolation), the causes of which are frequently outside an individual’s conscious awareness. (289)

Unlike the psychodynamic view, the managed care perspective understands psychiatric distress as episodic rather than endemic, as a “state” the per-son is in versus a “trait” that endures. Using a somewhat different theoretical lexicon, we might say that the managed care model construes authenticity as a technology of action, whereas the psychodynamic model con-strues authenticity as a technology of self (Foucault et al 1988). (290)

Specifically, borderline talk engages the conflicts between procedural and epistemic authenticity in a singular, if dis-turbing, way—by rendering epistemic authenticity itself impossible. (292)

If, to paraphrase Rhodes’s prison guard, Caroline’s behavior is construed as manipulative in large part precisely because she is a manipulator, then it becomes difficult for the clinical team to ever perceive her as acting authentically, regardless of her motivations. In a context where authenticity (procedural, epistemic, or both) is un-derstood as foundational to autonomy and psychological health, this rendering of Caroline as incapable of epistemic authenticity—because she has no authentic self from which to act—configures her as largely outside the purview of rea-sonable clinical intervention. It therefore upholds an evaluation of her treatment based on her outward actions alone. Under such circumstances, it becomes not only acceptable but ethical to discharge her from treatment until and unless she is prepared to invest in her own care, with the burden for demonstrating this readiness resting squarely with her. (293)

We can see how, in cases like Caroline’s, invoking borderline talk enables a provisional resolution of the authenticity problem by rendering any reliable subjectivity at all unattainable for a given client. This, of course, requires clinicians to negate the very thing they claim necessitates their existence as trained professionals—the “self” as an entity deserving of care. At the same time, this practice affirms and supports the ends of the managed care organizations. (293)