Nurture Before Responsibility: Self-in-Relation Competence and Self-Harm

Borderline personality disorder (BPD) is a disorder that affects mainly women and often manifests itself through self-injurious behavior and suicide attempts. The perception that these patients are themselves to blame for their self-destructive behavior is a common reaction when clinical practitioners are faced with this behavior. Recent philosophical work has tried to reconceptualize the responsibility of personality disorder patients (i.e., Pickard's responsibility without blame). In this article, I problematize the focus on responsibility as a conceptual and therapeutic approach to deliberate self-injury in patients with BPD. I suggest that this thin, content-neutral account of responsibility fails to properly consider the complex phenomenology of BPD selfhood and self-harm. Instead, I forward an alternative model based on a thick account of responsibility to examine in more detail the social formation of substantive content of the will. The article explains how borderline is a disorder of the self-in-relation, which tracks the socializing, relational factors that contribute to the development of a dysfunctional BPD selfhood premised on self-punishment, self-abnegation, and self-loathing. Moreover, the framework lends itself to an alternative normative standpoint to self-harming behavior in individuals with BPD, which focuses on the therapeutic nurturance and validation of emotion and needs, before the treatment of individuals as responsible agents. I explore how such a standpoint is applied in schema-focused and dialectical behavioral therapy treatments of BPD.