Articles: Commodity/Body/Sign:Borderline Personality Disorder and the Signification of Self-Injurious Behavior
By Nancy Nyquist Potter
Philosophy, Psychiatry, & Psychology - Volume 10, Number 1, March 2003, pp. 1-16
THE DIAGNOSIS OF the Borderline Personality Disorder (BPD) includes a number of symptoms that bear analysis in order better to diagnose and treat such patients. Although guidelines for those working with such patients have recently been published (e.g., in Psychiatric Services [2001]), they cannot provide a sufficiently rich framework for clinicians. Identifying behaviors such as manipulativity, impulsivity, identity disturbances, and self-injurious acts each need to be understood as concepts that are philosophically messy and complex. Furthermore, the majority of people diagnosed with BPD are women (Gunderson 2001, 54), so it is important to consider these concepts as they intersect with gender and other norms. My interest is, ultimately, ethical: what constitutes ethical responses to, and interactions with, someone whom we take to be exhibiting symptoms of BPD? But to build an ethical framework, I believe it is necessary first to probe from a philosophical perspective behaviors that correlate with BPD. This paper begins that larger project with an analysis of delicate self-injury. The second [End Page 1] half discusses ethical implications, focusing on one virtue—that of giving uptake.
One of the more troubling activities that characterizes people diagnosed with BPD is self-injury. Self-injurious behaviors also show up in some other personality disorders (Favazza 1989), but this analysis focuses on the intersection between BPD and self-injury. As John Gunderson says, the criterion of self-mutilating behavior "is so prototypical of persons with BPD that the diagnosis rightly comes to mind whenever recurrent self-destructive behaviors are encountered" (2001, 11). Hence, when I refer to self-injurious behavior, I am restricting the discussion to delicate self-injury done by persons diagnosed with BPD. To know how to respond to people who are self-injurious, clinicians need to know what it is. And it is trickier to answer that question than one might think. Definitions of actions falling in this category tend to be question begging, as this essay will suggest. Alderman (1997) summarizes self-injurious behavior as acts that are done to oneself, performed by oneself, physically violent, not suicidal, and intentional and purposeful. The literature distinguishes between delicate, or superficial, and severe self-mutilation, which is defined as "the deliberate infliction of direct physical injury on one's own body. . . that involves cutting, maiming, destroying or altering a part of one's body in a socially unacceptable fashion, and [which] may result in permanent disfigurement" (Parrott and Murray 2001, 317).
Causes of self-injury are also unclear. The most commonly supported explanatory theories are that such acts are kinds of ritual, symbolic expressions, or tension relieving (Zila and Kiselica 2001). Ross and McKay (1979) offer an array of possible causes of self-mutilation including ritual and symbolism, sex, regression, existential statement, manipulation, risk taking, attention seeking, retaliation, frustration, depression, tension relief, inappropriate communication, self-punishment, and low self-esteem (listed in Zila and Kiselica 2001). Diana Milia places self-injury in the "context of cycles of creation and destruction inherent within the creative process" and argues that its healing potential arises out of transformative elements that parallel ritual and other creative processes (Milia 2000, 12). Another theory posits self-injuring acts as an externalization of a woman's fears of being a passive victim of bodily attacks. On this view, fears grounded in a female physiology that is experienced as unruly and particularly vulnerable to invasion are defended against by being the one in control of the harm (Cross 1993). In general, the better attempts to understand cutting and other self-injuring activities view self-injury as employing a form of "default" rationality. On this view, what the person does is rational given her history and the way she views the world, but she acts in ways that are inconsistent with norms for living a flourishing life. As a response to trauma, cutting and other forms of self-injuring are highly adaptive responses. For example, Janice McLane (1996) argues that self-mutilation allows a trauma victim a "voice on the skin" when she is otherwise feeling silenced. On this view, the cutting says what the woman cannot put into words. The body, then, is being used to communicate something that is difficult or impossible to articulate in conventional modes (Crowe and Bunclark 2000; Milia 2000, 76; Miller 1994).
I want to suggest a way of thinking about self-injury that takes seriously its potentially destructive aspects while situating it in a broader discourse of body modifications where the body is being used as a text. To say that the body is text is to suggest that the body, like other mediums of communication, must be interpreted and that its meanings are not given or inevitable. "As a field of interpretive possibilities, the body is a locus of the dialectical process of interpreting anew a historical set of interpretations which have already informed corporeal style. The body becomes a peculiar nexus of culture and choice, and 'existing' one's body becomes a personal way of taking up and reinterpreting received gender norms" (Butler 1987, 133-134; see also Bordo 1989). On this view, one of the texts by which we communicate and engage in mutual meaning-making is the body. This way of framing self-injury raises questions about the role popular culture and psychiatry play in imbuing some acts as fashionable, others as transgressive, [End Page 2] and still others as pathological. It also brings into focus the increasing treatment of the body as a commodity and complex attitudes people have about bodies. My aim is to open up a space for clinicians to be able to respond to a patient who is self-injuring in a morally grounded and therapeutically effective way, drawing upon explanatory theories like the above to some extent but not letting them stand in for the hard work of interactive patient-clinician communication. Treatment is unlikely to be both ethical and effective until more attention is paid to these patients' own views of their behavior (Miller 1994). The task for clinicians—both a therapeutic and moral one—is to find out what, if anything, the patient means by the signs with which she communicates.
Meaning-Making and Responsibility
It is widely recognized that how we experience the world is shaped by our conceptual scheme. This observation has led some philosophers as well as some clinicians to take the further step of claiming that what we believe is true—what we count as knowledge—is (at least partly) determined by our conceptual scheme. On this view, in forming our beliefs—what we take to be true—we are not just passively impinged upon by an independently structured world but instead, through our conceptual scheme, we in some sense construct our representations of reality. The idea is that knowledge is not determined by the nature of things (Hacking 1999, 6); or that what we count as knowledge is always, to some degree, mediated by the particularity of knowers (Code 1991); or that any division between natural kinds and social production of those kinds is a priori indefensible (Gillett 1999, 73). It is important to note that a claim that something is socially constructed does not commit one to relativism, although a full discussion on this point is beyond the scope of this paper. It does, however, lead to the idea that how we interpret things is not independent of the social milieu in which beliefs, ideas, and values emerge, and that what we perceive, when we interact in the world, is always already mediated by norms and practices. Many clinicians are keenly aware that their perceptions, interpretations, and responses to patients are shaped by larger social and cultural contexts as well as value-laden theories of health and rationality. But it may be difficult to see how ideas about social constructionism can be applied to people who engage in self-injury. Still, I believe that that framework is illuminating in that it allows us to reorient a discussion of ethical responses to such cases. To provide a framework for ethical responses to, and interactions with, people diagnosed with BPD who self-injure, I draw on two concepts from theories of meaning: signification and uptake.
I'll start with signification. But first let me say something about body communications, because that is the domain of inquiry. Traditional philosophical analyses of communication focused primarily on speech acts and paid little or no attention to nonlinguistic signs. Critics, however, have argued that that way of conceptualizing communication is too narrow and that we employ numerous other modes of communicative interaction. We communicate through styles of dress, for example, through body "language," smoke signals, and with gift giving. Each of the various modes of communication raises ethical questions about norms for communicating with one another. To foster respect, friendliness, and community, communicative ethics must make a place for "gestures that bring people together warmly, seeing conditions for amicability: smiles, handshakes, hugs, the giving and taking of food and drink" and other embodied nonlinguistic acts (Young 1996, 129). Clinicians are trained to pay attention to a variety of modes of communication and so are well positioned to apply a communicative ethics where the body plays a positive role.
Now to signification. Signs are composed of a signifier (marks on a page or sounds or movements) and a signified (what those marks or sounds or movements mean). The signified, then, is the sense or meaning inscribed in a term or gesture. The task of a potential listener is to determine whether or not something is being communicated and, if so, to interpret it. The [End Page 3] listener or audience does not do this alone; he relies on linguistic and other conventions to infer meaning. Part of this reliance involves the assumption that the communicator is employing a particular sign because she believes her audience will recognize the intention to communicate and pair it up with the intended meaning. (For example, if I am lost and build three fires in a row, I am doing this because I think that someone seeing them will conclude that I wanted someone to recognize that sign and infer that I need help.) But as W.V.O. Quine argues, conventions do not just spring into being; they are brought into being by the behavior of the parties to a given convention (1960). This means, on Quine's view, that "facts" about behavior are not enough to determine whether a given understanding of that behavior is correct. Consequently, we can conclude that interpretation is required, and interpretation is not a science but, instead, an art. I like the way Grant Gillett characterizes the discursive view of communication, which he says
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locates a person in relation to a sphere of discourse and allows one to identify the position he or she is taking and the subjective relationships holding between the person and the context. These reveal how it is to be that person and what choices for perception and action present themselves in a given situation. This in turn illuminates relationships of power, reveals the content of any significations used to organize behavior, and renders understandable the activity of the person concerned; it is as if one were to successfully locate a person on a map so that you and they both remarked, "Ah, now I see where I am!" (Gillett 1999, 28-29).
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What I think is right about this way of understanding explanation (e.g., a patient's explanation of her self-injuring behavior) is that it situates the communicator and audience in a discursive field in a context of power relations. Yet the greater weight of explanatory power in interpretation and meaning-making are placed in the hands of the person whose behavior calls for explanation. I will return to these points later.
The body is one kind of text, and the things it does are units of meaning within a discursive field. With my body, I express the idea "I am a woman" through a myriad of signs of femininity that others know how to read. Movements like soft, gentle hand gestures, touching the hair on one's head, crossing one's legs, and tilting one's head are conventional signs of femininity.
But we make mistakes in our interpretations of signs all the time, including mistakes about gender. Signifiers for gender are like signifiers for Santa Claus—although sense-making, neither refers to anything real. In fact, signification necessarily relies on the construction of a metaphysics that disguises the arbitrariness of its own processes (see Derrida 1974, 12-14; 1981, 30-32). 1 That is, signs get their meaning from their relation to other signs. We rely on conventions of meaning to communicate with one another, but we are too often seduced into thinking that those conventions are reliable. As Gillett says, "it is clear that the realm of discourse is not only an interpersonal realm but also that it cannot be understood without paying some attention to its social and cultural context" (1999, 31). For example, Marilyn Frye argues that, because linguistic and cultural conventions equate women's anger with bitchiness, hormonal changes, cuteness, or irrelevance, women's anger at moral injustices done to them do not get taken seriously and respectfully; instead, cultural norms allow men to minimize, trivialize, pathologize, mock, and ignore women's anger. "As a social act, an act of communication, [women's anger] just doesn't happen" (Frye 1983, 89). When interpreting another's signs, then, we need to be skeptical about cultural imperatives to appeal to conventions that close off alternative meanings or that impose meaning in ways that rob the speaker of her voice.
In interpreting what I will call body signifiers, the first thing you need to ask is whether the signifier has any meaning (that is, is it a sign?). If you determine that you are picking up a sign, your task is to interpret it. Even here, we can make mistakes. Consider an act of burping. In our culture, burps generally are not taken to be "saying" anything. But cultural meanings of the burp vary, which suggests that even knowing when to take seriously a signifier is sometimes complex. We can also err by assuming a signifier has meaning when it may not. Contrast my friend's utterance "one strawberry ice-cream, [End Page 4] please" with the signifier "butterfly tattoo" on her left breast. I might ask why she ordered ice cream, but her answer is likely to satisfy me without my needing to probe for more: she just likes it; it is a matter of taste. The tattoo might be a bit more difficult for me to appreciate; the answer "Tattoos look cool" is a matter of opinion that I may find harder to wrap my mind around. But if I were to push her on the meaning of tattooing in her life, I seem to be assuming that tattooing is not like eating ice cream—a matter of taste—but that it signifies something that requires further explanation. When I decide that signifying coolness is not enough of an answer, I may be looking for deeper meaning that just is not there. But as I have said, we do not make decisions in a cultural vacuum about whether, in a given situation, to accept the relativity of taste or, rather, to press for further explanations: cultural norms influence our interpretations and responses to others' signifying acts.
Now to self-injury. The going wisdom about self-injury is that the person engaging in such acts is trying to say something. My first point, then, is that that general assumption should not be made a universal. Research suggests that some self-injury may be merely a response to physiological stimuli, so not all self-injury has meaning. But second, interpretations of self-injurious acts tend to appeal to a restricted domain of meaning that assumes an underlying psychological anguish in the actor. Although difficult for me to imagine, I believe it is logically possible for someone to enjoy the experience of watching blood drops form on her arm after cutting herself—and for her to hold no other meaning than an aesthetic one. But meaning making is cultural and communal, and an assertion that one's self-injurious act is merely aesthetic may not be enough for others to let the matter rest. We draw on values and beliefs when interpreting signs, but what warrant do we have for aligning a given value or belief with a particular signifier? When we interpret signs written on the body, we must be skeptics with respect to cultural and linguistic norms. When a person is expressing something by cutting or burning herself, we need to remain open to what she may—and may not—be saying. We need critically to attend to the conventions we draw upon to interpret such signs, and to question the cultural norms that delineate when it is and is not acceptable for a person to injure herself with the goal of giving herself aesthetic pleasure. In the next section, I illustrate how complex the matter of body as text can be.
Situating Self-Injury
The deployment of the body as a text is not unique to those with personality disorders. Body modifications can represent aesthetic, religious, or political values. These days, people tattoo themselves, get body piercings and penile enhancement, color their hair purple, lighten (or darken) their skin, and go on starvation diets. Historically, religious people have fasted, flagellated themselves, and discovered stigmata as signs of deep conviction. Lakota people have practiced sundance rituals. Protesters and laborers have gone on hunger strikes. In all these cases, the body is being used as a text. And in all cases, some degree of risk taking and pain are involved. But interpreting the various signs is messy and complicated indeed. Is tattooing, for example, a fashionable form of self-expression or a sign of pathology (Inch and Huws 1993; Sanders 1989)? Let's consider an array of intentional actions that bring about body modifications, all of which involve some degree of risk and pain.
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1. Tattooing
2. Body piercing
3. Surgical implants
4. Scarification
5. Pigmentation changes (skin lightening or tanning)
6. Radical dieting
7. Hunger striking
8. Fasting
9. Stigmata inducing
10. Cutting and burning2
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Several points emerge from this brief look at body modifications. In each kind, to understand what is being "said," we have to consider not only the cultural norms that shape meaning and interpretation, but also the individual communicator. What is being communicated and how it is meant to be received cannot be easily identified. [End Page 5] For example, there are theories about the cultural meanings of tattooing and scarification, but they offer hypotheses of general public meanings that may not be applicable to given individuals. A person with a tattoo may not be clear what her intentions are with regard to the tattoo, or she may not intend to produce any effects on others. Many kinds of body modifications are imitative and, although meanings are constructed (often post hoc), a participant may not intend to say anything other than a reflexive "me too." Note, too, that the question "Why did you do such-and-such an act of self-injury?" can be answered in terms either of explanation/motive or of meaning/intention to communicate, and this ambiguity creates its own problems in interpretation. If I offer an explanation in response to your "why," but you continue to seek for a deeper meaning, which of us should decide when the question has been answered? When ought an answer be sufficient to satisfy others? I also observe that these actions can be grouped in various ways.
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The first five are "amateur or professional," whereas the last five are "self-injuring."
The first six are "aesthetic," the next one "political," the next two "religious," and the last one "pathological."
The sixth and the tenth are "pathological" and the rest are "socially acceptable."
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Furthermore, some kinds of body modifications do not lend themselves to any of the above groupings in an obvious way. Amputation for nonmedical reasons seems to be sought for reasons of identity rather than purely aesthetic or other reasons. For example, one person says "My left foot was not part of me" to explain the desire for amputation (see Elliott 2000.) Penile enhancement may also be sought as a matter of identity or self-worth. Are body modifications that are identity affirming still self-injuring? Why would one kind (penile enhancement) be socially acceptable and the other (amputation) be pathological? Complicating these groupings even more is the claim by some tattooed people that their tattoos are an expression of identity (Bell 1999; Sanders 1989.) Do these different identity-conferring "self-injurious acts" have something in common that we are not understanding?
It is not clear what justifies these groupings. Clearly, attitudes about what is proper and acceptable to do with one's body play an important role in interpretations of body signs. In tattooing, for example, even if the signified is about belonging, the tattoo is part of how its signification gets interpreted. We signal belonging in many ways: T-shirts, bumper stickers, and flags, for instance. When the signifier is written on the body, its materiality is itself important. The chosen mode of signification, therefore, is part of the signified. Yet it is unclear what criteria we use in assigning sense and meaning to these various body signs.
As a culture, audience responses to this variety of body modifications are sometimes tolerant, other times oddly intractable. If we view a body alteration as aesthetic, political, religious, or identity conferring, we may negatively evaluate it but eventually seem to drum up toleration. In those cases (students with nipple piercings, colleagues who fast), we make an effort to be tolerant even when we do not ourselves appreciate, understand, or endorse the sign. This is even true of the excessively thin models who evoke admiration and envy (but not judgments of pathology) in virtually everyone but health experts. What is so objectionable about cutting or burning that it cannot elicit tolerance like (for instance) scarification of some African tribal peoples?
Blood letting has ancient communal roots that merit examination in this context. Zila and Kiselica note that ritual and symbolism is one of two most commonly supported theories about causes of self-injury (the other being tension relief.) Those authors, drawing on earlier research, note that "Ross and McKay (1979) explained ritual and symbolism in descriptions of self-mutilation that are laden with religious overtones and symbolism. Favazza and Conterio (1989) concurred with this theory, citing frequent references to the need to atone for sins by those who self-mutilate. Himber (1994) found a common theme of self-purification among these individuals" (Zila and Kiselica 2001). There are many reasons a community engages in blood sacrifice, including pacification of afflicted spirits (Turner 1967) or payment of homage, atonement, or purification to [End Page 6] deities (Burkert 1983). I will discuss one theory of sacrifice that may illuminate some self-injurious behavior.
Milia argues that, although sacrifice and symbolism have recognized cultural currency, one purpose of sacrifice is to draw boundaries between good and bad violence and to reestablish order for a community. Sacrifice, then, is a special kind of violence that the community approves of and controls through ritual and symbolism (Milia 2000, 17). The need to create order out of chaos and thus reassure requires that violence and blood letting be further designated as good or bad kinds:
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Just as violence has been split into good and bad types—that which is sanctioned for the purpose of maintaining societal order and that which is unlawful—blood has also been classified in opposite types. . . . The dual nature of blood becomes apparent as its presence represents the life force, and its spillage heralds the draining away of life. (Milia 2000, 18)
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What is striking in Milia's account is the suggestion that the transformative quality of sacrifice and its symbolism is in its duality. "Symbolically, the sacred victim [of sacrifice] comes to represent that which is both evil and transcendent of evil. The ritual of sacrifice forms a bridge to transcendence of sin, and in this way accomplishes purification" (2000, 17). This analysis, then, suggests that the sign may not be just one thing—it may contain paradoxical concepts—and clinicians will need to look for contradictory meanings (and not push for an artificial or early resolution.)
Still, the question remains why body modifications are given the meanings they are. Milia suggests that, even when mainstream culture views some body modifications as socially deviant or transgressive, they are not viewed as pathologies if they are meaningful at least to a subculture. Tattooing, scarification, and body piercing are signs that transform self-injuring wounds into aesthetic expressions. This transformation purifies its violence and reenacts rituals of human sacrifice at a higher level of symbolism (Milia 2000, 26). Cutting or burning, however, when done alone and in secret, fall outside culturally acceptable meanings of aesthetic, ritual, or political significance (Milia 2000, 43).
Furthermore, contemporary culture has generated panic and distrust about bodily fluids, displacing fears about external threats onto the secreting, leaky body.
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The rubber gloves the Washington police force insisted on wearing before touching the bodies of gays who were arrested at recent AIDS demonstrations in Lafayette Park across from Reagan's White House; the sexual secretions in contemporary American politics where presidential candidates, from Hart to Celeste, are condemned out of hand by a media witchhunt focussing on unauthorized sexual emissions; and routine testing, the Reagan Administration's bureaucratic term for the mandatory policing of the bodies of immigrants, prison populations, and members of the armed services who are to be put under (AIDS) surveillance for the slightest signs of the breakdown of their immunological systems. (Kroker and Kroker 1987, 12; emphasis in original.)
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The distinction between good and bad body modifications, therefore, may indicate cultural responses to perceived evil or impending danger. Nevertheless, as Milia suggests, the distinction really seems to amount to a difference between what the culture understands and does not understand (or between what it is willing to understand or not).
Finally, although I am not arguing for a new taxonomy for BPD, I do think this broader view of body modifications suggests that self-injury (or self-mutilation, for that matter) does not pick out a persuasive set of factors for pathologizing body-related actions of someone diagnosed with BPD. Historically and cross-culturally, then, there is a variety of potentially harmful body modifications, and they intersect with cultural norms in complex and varied ways.
The next section situates self-injury more broadly in the context of cultural, political, and economic attitudes about the body.
Commodity/Body/Sign
In this section, I consider the possibility that some self-injurious actions have meaning, but argue that that meaning may indicate cultural, rather than individual, pathologies. Where body modifications are concerned (cutting and burning included), self-injuring may signify a reaction [End Page 7] against dehumanization (Milia 2000, 47). One theory of self-injuring suggests that, by harming the body, the individual highlights a distinction between body and self (Zila and Kiselica 2001).
The typical self-injurer is female, adolescent or young adult, single, from a middle- to upper-middle-class family, and intelligent (Favazza and Conterio 1989; Suyemoto and MacDonald 1995). One study found that the difference between patients with BPD who engaged in self-mutilation and those who did not could not be explained by different histories of abuse or by levels of dissociation (Zweig-Frank et al. 1994). Rather than looking for meanings that go back to childhood experiences, clinicians might explore ways that the culture produces such expressions. Like tattooing and other accepted forms of body modification, cutting and burning may be imitated actions and, in fact, research suggests that social contagion may be a factor in self-injury (Zweig-Frank et al. 1994). But instead of it signifying a contagion of individual pathological behavior, it may signify those individuals' locations in social and economic systems. Because most of those who delicately self-injure are female, I focus here on female bodies.
Robert Mitlitsch (1998) argues that late capitalism has amplified a commodification of the body. The sign-value of the body has increasingly come to hold aesthetic promise as well as use/exchange value. Commodification, then, performs the cultural labor of signification. As the global economy becomes increasingly consumer oriented, and the body is conceptualized as another commodity to market and remake as desirable, the body is susceptible to objectification as never before (for just one example, see Morgan 1991).
Women's bodies are commodified specifically in sexual ways. (Women's bodies are also commodified in the service of reproduction, but I do not delve into that issue here.) Women still internalize cultural views that their primary value is in evoking sexual desire and delivering up sexual pleasure. Normative femininity includes standards of beauty that picture women of value as impossibly thin and attractive. Whether or not an individual woman resists these norms, she must objectify herself to evaluate herself and decide how to respond to those norms.
The distress expressed by women diagnosed with BPD may not be unique, but rather may reflect a more general experience of being female in our culture (Miller 1994). The female body in literature and popular culture has been both extolled and despised, eroticized and reified and yet viewed with disgust and distrust. Female being is conceptualized and represented as a being to be perceived (Bartky 1990; Berger 1972; Bourdieu 2001; Kaplan 1983). Body image, for many women, is fragmented into parts (a pretty waist, an ugly nose) rather than as a whole, embodied self (Cross 1993). This claim is borne out by research on attitudes self-injuring women have about their bodies: "More than half of the [self-injuring] participants in Favazza and Conterio's (1989) study reported the presence of troublesome sexual feelings: 34% hated their breasts, 56% strongly hated having a pelvic exam, and 10% indicated they would be better off without a vagina" (Zila and Kiselica 2001). But these findings are not specific to those who self-injure. Body loathing is not surprising given cultural attitudes about women's bodies.
Furthermore, female physiology contributes to women's experiences of their bodies as discontinuous and alien. Partially internal genitalia, with their ambiguous and mysterious workings, relatively abrupt changes in body contours during puberty and pregnancy, and menstruation with its pain and messiness give rise to experiences of embodiment that are ambivalent at best. Female physiology intersects with a culture that, in particular, commodifies women's bodies, overdetermining a metaphysics of the body as object.
In the context of an economy and culture where body commodification and objectification proliferates, women become increasingly alienated from their bodies (see, for example, Emberley 1987). Hence, the need increases for women to experience their bodies as real. This can prompt a (perhaps unconscious) transgressive response in an attempt to real-ize the body as "one's own." (Trangression is used here in the cultural sense, rather than in the sense of sin and evil, and is sometimes used to praise acts that violate repressive norms. For a discussion on an ethos of transgressive acts as acts of resistance to socially controlled and disciplined bodies, see Passerin-d'Entreves 1999; see [End Page 8] also Marchak 1990). Judith Butler, drawing on Mary Douglas's theory of the body, says that whenever boundaries of the body are established, the taboos about the limits of those bodies become naturalized (made to seem natural) (1990, 131). And Douglas, in a passage that resonates with Milia's analysis of the duality in sacrifice, writes that "ideas about separating, purifying, demarcating and punishing transgressions have as their main function to impose system on an inherently untidy experience. It is only by exaggerating the difference between within and without, above and below, male and female, with and against, that a semblance of order is created" (Douglas, as quoted in Butler [1990] 131). The point is that what constitutes the limit of the body is signified by taboos and anticipated transgressions.
Self-injury is a taboo because it transgresses an imposed boundary that seems, to us, natural and given—the boundary between body and self, between material and immaterial, and between subject and object. As the body is increasingly destabilized and disposable, it requires more and greater transgressive acts to produce the appearance of substance. Cutting and burning, then, might be understood as an attempt to "own the body, to perceive it as self (not other), known (not uncharted and unpredictable), and impenetrable (not invaded or controlled from the outside)" (Cross 1993). Still, this interpretation may not be what an individual woman means when she cuts or burns; asked why she cuts herself, an individual may not explain things this way. And clinicians may still want to convince her not to resist commodification this way, arguing for better ways to "produce the appearance of substance." My point is that the audience is unlikely to learn the meaning of the sign in a given situation unless it learns to listen differently.
Communicative Ethics When the Body is Text
Clinicians are often at a loss to understand the actions of individuals who self-injure. Many find it difficult to talk about the self-injury in a way that allows the patient a role as interpreter of her own signs (Favazza 1996; Himber 1994). "Ross and McKay (1979) found that only after conceding that they did not understand self-mutilation were counselors then able to suspend clinical judgment and allow the young women to explain their behavior" (Zila and Kiselica 2001).
This brings me to the second concept in communicative ethics—that of uptake. 3 An understanding of this concept can help clinicians talk with their patients about self-injury with the openness I advocate. Uptake is a linguistic concept introduced by J. L. Austin (1975) to characterize the role of the listener in securing the meaning of a speech act. According to Austin, when the listener receives another's speech act with the conventional understanding, the listener has given the speaker uptake. For example, one cannot be said to have warned an audience unless that audience hears what one says and takes what one says in a certain sense, say as an alarm, an alert, or a threat (571). Another example is that of promising: my promise to you can be said to be successful when you understand my speech act as one in which I place myself under obligation to you.
But many of the conventions of language are bound up with social conventions and power relations, which can elide the voice of the disempowered. So giving uptake cannot simply be a matter of relying on norms and conventions of communication. Frye, expanding on Austin's idea, discusses uptake in terms of anger: "Being angry at someone," she writes, "is somewhat like a speech act in that it has a certain conventional force whereby it sets people up in a certain sort of orientation to each other; and like a speech act, it cannot 'come off' if it does not get uptake" (Frye 1983, 88). Uptake, then, occurs when the second party, listening to my speech act, reorients herself to me and the relation between us "comes off" with an appropriate response. Women, Frye argues, typically do not get uptake on their anger because cultural norms allow men to ignore or trivialize it. Although gender is not the only axis of power—and a straightforwardly binary account of language conventions in terms of gender would be oversimplified—Frye is right to identify patterns of relating that follow structural power relations. A proper response is one that conveys an empathetic attitude toward the communicator or an earnest attempt to understand [End Page 9] things from the communicator's point of view. But it is difficult to empathize with (or just take seriously) people who seem to be very different from us, and societal norms often discourage it; in this way, relying on patterns and conventions may impede, rather than facilitate, understanding.
In giving uptake, we still may not agree with the communicator; we can take others seriously and yet disagree. But when we take another seriously, we also take seriously the reasons that person gives for her actions and beliefs. To give uptake rightly, then, it is not enough simply to receive another's communication with the conventional understanding. We must try to understand what the world looks like from the communicator's position. This may require that we set aside preconceived ideas about value and meaning.
Of course, as deployers of signs, we do not always know what we are trying to communicate or our reasons for communicating something. Still, there is a danger in disregarding a communicator's explanations and drawing, instead, on cultural norms or in assuming we know more about a communicator's meaning than she herself does. Listeners' responses to survivors of the Holocaust, for example, often clutch at a familiar lexicon that wards off the discomfort and fear that arises when hearing about an alien moral landscape (Langer 1991). For example, when Hanna S. says she survived through luck and stupidity, the interviewer protests "No, you were plucky." Langer argues that interviewers of Holocaust survivors override the speakers' interpretations of events out of a desire to preserve preconceived associations between victims of evil and heroic survival. In this context, though, familiar moral vocabulary and norms are irrelevant to a discourse that attempts to give voice to experiences of the Holocaust. The survivors are mining their common and deep memory about their experiences, thoughts, and feelings, but the interviewers have (or make) no cognitive or moral space to accept as real the things they are being told. The interviewer fails to give uptake to the speaker by refusing to grant validity to the speaker's different system of signs. Instead, she explicitly discounts the interpretations given by the speaker telling the story.
We can extrapolate from Langer's analysis to a communicative ethic for clinicians who work with patients who self-injure. We have few, if any, language conventions to lead us through discourse about self-injury in a way that preserves the integrity of the communicator. Without conventions that are appropriate to the specific participants of a conversation, most hearers fall back on familiar conventions rather than charting this new territory.
Another aspect of giving uptake, then, is that one does not impose interpretations and meanings that the (other) communicator is unwilling to receive except through coercion. People in positions of authority (parents, teachers, clinicians) can put pressure on others to acquiesce to their interpretations, and giving uptake rightly requires that we guard against such tendencies. Clinicians, among others, have the ability to silence the communications of the less powerful, and one effective way to do that is to stop a communication from counting as the action it was intended to be (Langton 1993). In other words, relying on the conventions of one's own culture, place, and time may skew a listener's ability properly to give uptake to the communicator. It is true that, in trying to give uptake properly—and by holding meanings open rather than closing them off—a clinician may be left with little common ground by which she can receive and understand another's communications, and that experience can be quite disconcerting—frightening, even. But it is my belief that the communicative struggle, in this situation, is integrally bound up with being an ethical clinician. Genuine understanding is not easy to come by, and we should expect it to call for moral, as well as epistemic, effort.
Communicative Maxims That Guide Giving Uptake
Let me now fill out these ideas a bit more. In analyzing the logic of communication, H. P. Grice introduced principles and maxims for conversation, such as "Do not make your contribution more informative than is required," "Be relevant," and "Do not say that for which you lack adequate evidence" (1989, 26-27). Extrapolating [End Page 10] quite freely from Grice's maxims, I offer five communicative maxims to guide the giving of uptake where the focus of therapy is the self-injurious behavior of people diagnosed with BPD. These maxims are for a restricted domain; they may not apply for other diagnoses or for other identifying behaviors of BPD.
Approach Discussions of Self-Injury with the Principle of Charity
The principle of charity holds that, rather than thinking that what a person has communicated is false, we try to interpret what a person communicates as true. I suggest that clinicians employ this principle when talking with BPD patients about self-injurious behavior. According to philosopher Donald Davidson, a theory of meaning allows us correctly to interpret the communications of others. But we do not yet have an adequate theory of meaning when it comes to self-injurious behavior, so we cannot know a priori what meaning a given self-injurious act has (Miller 1998, 263-273). If understanding a patient involves something like interpretation, then we can either aim for preserving truth in a communicative exchange or for preserving meaning. Davidson's argument is that a theory of meaning ought to adopt the principle of charity as an attitude an interpreter takes before he or she can interpret.
I recognize the contentiousness of suggesting that patients diagnosed with BPD be approached with the principle of charity. Such patients may have cognitive difficulties that hamper their grasp on reality, so readers may question the value of assuming communicator truth in such cases (Gunderson 2001; Kroll 1988). On the other hand, the two main cognitive problem areas for BPD patients—reality testing and thought processes—occur mostly under episodes of stress and seem to be relatively strong and intact otherwise (Goldstein 1995). So let me try to motivate this maxim.
The argument I have advanced concerning self-injury is that it can be located among various body modifications found across cultures. It is unwise to assume a priori that we know what a given signification means. It is important to resist the rush to judgment that a patient's actions are irrational or pathological without exploring the patient's own interpretations and explanations for her behavior. What I am suggesting here, then, is that clinicians should assume that, in the circumstances in question, the patient has beliefs that, by our lights, are true (Miller 1998, 270). What this amounts to is that the clinician hold beliefs constant as far as possible while solving for meaning (Miller 1998, 270). The value in this approach is that it slows down the interpretive process and shifts more of the right and responsibility for meaning-making to the patient. Adopting this principle, then, would create a space for the clinician to interpret with her patient the actions under scrutiny, while allowing the patient to take the lead.
Note that this maxim applies to a very restricted domain: it concerns patients diagnosed with BPD, and only with respect to communications about self-injury. What I am proposing, in effect, is that clinicians bracket off their evaluative skills and capacities to the degree that they are not distracted by judgments about truth value while therapeutic work is being done on the subject of self-injury.
Take a Critical and Reflective Stance toward Your Own Conceptual Framework
Although none of us can step outside of culture altogether, we can evaluate our attitudes, beliefs, and values from a second-order level (Taylor 1989; Frankfurt 1971). Complete objectivity is an unlikely ideal. But clinicians can, and should, think critically about ways in which prevailing norms and values may be influencing their understanding of the world and their ways of being in it. They need to be on guard against subtle assumptions about health, rationality, and good actions that could be misguided in the case of a particular patient and thereby inhibit that patient's ability to heal.
Adopt a Position of Epistemic Humility and Moral Uncertainty about Meanings and Explanations for Self-Injury
Related to the last maxim, this one encourages the clinician to be open to discovery. To do [End Page 11] that, the clinician needs to be somewhat skeptical toward her own confidence level with respect to general meanings about self-injury. She should suspend judgment to the degree she is able without jeopardizing the short-term physical safety of the patient. Clinicians must be concerned about imminent danger, so this maxim cannot always be applied. But taking a longer range view, this heuristic allows the clinician to work with the patient in exploring meaning and to participate in meaning-making that is not prematurely closed off.
Recognize That the Patient, Too, May Bring Assumptions about Her Behavior That Are Culturally Inflected
This is, perhaps, a call for balance between adopting the principle of charity, on the one hand, and taking the patient's point of view as the final one, on the other hand. Taking an explanation or a meaning as "true," in this case, does not commit the clinician to any particular theory of truth. Patients may be believed about their own interpretations, but clinicians and patients together may want to unpack patients' conceptual framework regarding self-injury. Patients are likely to pick up the idea that people who self-injure are pathologically demented, and that attitude may be expressed by the patient in therapy, but it is important to try to identify whether the patient is distressed by her own behavior or whether she just believes that she ought to be.
When Asked to Give an Interpretation, Offer Disjunctive Ones
Sometimes a patient will ask the clinician for assistance in understanding her actions, and sometimes the clinician will want to offer alternative interpretations to the one the patient is offering. In the spirit of openness and a commitment to patient autonomy, clinicians should offer an array of interpretations so that the patient can explore various possibilities to see which best fits. Or, the patient and clinician may brainstorm together about possible meanings. The point is not to impose an interpretation that the clinician thinks is correct, and not to close off opportunities for discovery or new knowledge. When offering disjunctive possibilities for interpretation, the clinician may need to avoid simple either/or statements, because patients with BPD are already prone to thinking in dichotomous extremes and need to be encouraged to think in more complex terms.
The aim of these maxims is to preserve the integrity of the communicator vis-à-vis her unfolding understanding of her self-injurious behavior. The value in it is that it facilitates greater understanding of the patient's experience. But clinicians may assent to the usefulness of such a communicative ethic while remaining unconvinced of its force. I now turn to questions of justification for such an ethical stance.
Giving Uptake as an Obligation
Elsewhere, I have argued that giving uptake is a virtue (cf. Potter 2000, 2002). Let me briefly sketch the ideas of virtue ethics and explain how uptake fits into a general theory of virtue.
A virtue is a state from which a good person feels, makes decisions, and acts rightly according to what the situation calls for. Virtues are essential to living a fully flourishing life. Virtues of character such as friendship, justice, trustworthiness, industriousness, and integrity enrich us personally and help us live with others cooperatively. Some virtues are corrective, in that they draw us away from human tendencies toward such things as selfishness or laziness. The virtue of giving uptake rightly is a corrective one. All of us are liable to be, at times, dogmatic and overly confident about our own beliefs, values, and interpretations. We tend to become entrenched in our own world views and dismissive of others whom we take to be wrong. We may try to impose our views on others and to dominate them in communicative interactions. Because of these problems, John Stuart Mill (1978) urges us to take other points of view seriously so as to foster freedom of thought and speech and to increase truth. Mill characterizes this dialogical problem as a tendency in people to be unwilling to entertain opposing points of view. A disposition [End Page 12] to give uptake rightly, then, can serve as a corrective for people who respond to others with arrogance or whose feelings of certainty lead them to discount the views of others.
Many of the virtues have a scope by which they can be identified. The scope of courage is feelings of fear and confidence about frightening things; the scope of temperance is bodily pleasures and pains of touch and taste. The scope of the virtue I call "the disposition to give uptake rightly" is dialogical responsiveness and openness in the context of plurality and power relations.
All of us need to cultivate the virtue of giving uptake; the virtues in general are central to being a good person and living a good life. Living a good life is not only an individual task; we need to help bring about the conditions for a good life for others as well. Virtue is social and communal, and living well is not just a goal for you or me, but for all of us together. Giving uptake is a crucial corrective to our tendency to be overly committed to prevailing norms and conceptual schemes. Being entrenched in a conceptual scheme or cultural milieu impedes our ability to communicate across differences, to expand our body of knowledge, and to foster democratic practices.
Clinicians, too, have an obligation to become the sorts of persons who will give uptake rightly. The primary obligation of clinicians, as for all medical practitioners, is to promote health and/or healing. To that end, professional codes of ethics charge clinicians with a duty to uphold values common to all medical practice, including respect, autonomy, dignity, benevolence, and nonexploitation (Radden 2001). These values are important in that they set constraints on clinician-patient interactions so that relief from patient suffering and distress is facilitated as much as possible and not exacerbated or frustrated by a damaging therapeutic relationship. These values and duties of medical practice are part of a larger moral landscape in which we recognize that all human beings have certain basic needs that must be met in order to live a life of minimum suffering, and that some of those needs are in the moral domain. Most clinicians, I believe, are committed to professional standards of ethics. But, because we are culturally shaped, clinicians do not come to encounters unmediated. All of us perceive, reason, and evaluate through conceptual schemes that are embedded in socially situated norms. So for clinicians fully to embody the values and commitments of medical practice, they need to extend their ethical framework. Learning to give uptake is an instance of ways that clinicians need to stretch themselves morally and, because uptake is a virtue, it is part of what is involved in living well.
Clinicians need to give uptake to patients who self-injure, then, because it is part and parcel of treating others with respect and dignity. Giving uptake need not assume that self-injury itself is a communicative act. What clinicians need to give uptake about is the patient's perspective on her self-injurious acts. For the reasons I have argued, it is particularly difficult to understand self-injurious behavior and to know how to situate it in relation to other body modifications. When confronted with patients who self-injure, clinicians are in need of a corrective to the tendency to interpret a priori the meanings of such significations. Without the virtue of giving uptake, clinicians run the risk of silencing or distorting the communications of their patients.
There is a second reason clinicians are obligated to develop ethical responses to patients who self-injure by cultivating a virtue to give uptake, and that reason has to do with the relation of uptake to trust. Noting that a central component of any ethic is communicative, I point out that failure to give uptake can impede patient trust in the clinician. Good communication both requires and fosters trust, and trust is a crucial moral dimension of the therapeutic relationship. Being trustworthy requires that we take care not to exploit the vulnerability that comes from placing trust in us or needing care from us (cf. Potter 2002). Patients are vulnerable to the power, knowledge, and expertise that comes with being a clinician and may be concerned about being misunderstood or interpreted in ways they disagree with. Giving uptake is also morally important, then, because it fosters trust when patients experience their clinicians as sensitive to the vulnerability of their patients; being trustworthy, because it is nonexploitative and nondominating, [End Page 13] facilitates therapy. But it would be a mistake to cast trust in purely instrumental terms. Although it is true that proper trust may foster healing, being trustworthy is intrinsically good. Like friendship, trustworthiness needs no further justification, even though benefits may derive from it. It is also a mistake to construe therapeutic interests as separate from ethical ones. Both are concerned with helping others live as flourishing a life as possible. When aims conflict, therapeutic healing must build into the relationship a way to mend broken trust and restore moral equality (cf. Potter 1996).
There is a third reason for clinicians to take seriously the claim that a good clinician gives uptake to her patients, and that is an epistemic one. Responsible knowers make efforts to perceive and to understand correctly. To the extent that our own conceptual schemes inhibit our ability to grasp meanings other than ones we are already prepared for, we may miss important truths. Clinicians, because they are trained to perceive pathologies and to interpret patients' behavior in ways that are consistent with prevailing norms for femininity, health, rationality, and propriety, may inadvertently impose interpretations on their clients. To do this, though, runs the risk of ending up with mistaken belief. To be a good healer, the clinician must have accurate knowledge. To gather correct knowledge, the clinician needs to listen to the patient in ways that allow for new knowledge to emerge.
Cultivating the virtue of giving uptake, then, can facilitate clinician understanding of the difficult and complex behavior of delicate self-injury engaged in by people diagnosed with BPD. This virtue is only one among many that clinicians need to treat patients in a therapeutically and ethically grounded manner. Compassion, integrity, justice, intellectual virtue, and others are also central to being a healer and therapist. Virtues are not the special provenance of clinicians, either: we all need the virtues. It is also true that being virtuous will not, in itself, heal the mentally ill. Patients diagnosed with borderline personality disorder who self-injure may need to form contracts, be prescribed medications, and so on. But part of knowing how best to treat a particular self-injuring patient is coming to an understanding of what such behavior means to that patient, and to do that requires an ethics of communication, a central feature of which is the virtue of giving uptake.
Acknowledgment
I would like to thank Jennifer Radden, John Sadler, Jerry Kroll, Robert Kimball, and three anonymous reviewers for giving helpful suggestions and criticisms on earlier drafts.
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Endnotes
1. See my "Liberatory psychiatry and an ethics of the in-between" for a discussion of the implications of postmodernism for psychiatry.
2. Some of these body modifications may be considered ornamental (body piercing in the United States; scarification in some African tribes), and some of these body modifications serve to identify group memberships (scarification may signify a particular ethnic identity; tattooing may signify belonging to a self-chosen community).
3. This section draws on my earlier work (Potter 2000).
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THE DIAGNOSIS OF the Borderline Personality Disorder (BPD) includes a number of symptoms that bear analysis in order better to diagnose and treat such patients. Although guidelines for those working with such patients have recently been published (e.g., in Psychiatric Services [2001]), they cannot provide a sufficiently rich framework for clinicians. Identifying behaviors such as manipulativity, impulsivity, identity disturbances, and self-injurious acts each need to be understood as concepts that are philosophically messy and complex. Furthermore, the majority of people diagnosed with BPD are women (Gunderson 2001, 54), so it is important to consider these concepts as they intersect with gender and other norms. My interest is, ultimately, ethical: what constitutes ethical responses to, and interactions with, someone whom we take to be exhibiting symptoms of BPD? But to build an ethical framework, I believe it is necessary first to probe from a philosophical perspective behaviors that correlate with BPD. This paper begins that larger project with an analysis of delicate self-injury. The second [End Page 1] half discusses ethical implications, focusing on one virtue—that of giving uptake.
One of the more troubling activities that characterizes people diagnosed with BPD is self-injury. Self-injurious behaviors also show up in some other personality disorders (Favazza 1989), but this analysis focuses on the intersection between BPD and self-injury. As John Gunderson says, the criterion of self-mutilating behavior "is so prototypical of persons with BPD that the diagnosis rightly comes to mind whenever recurrent self-destructive behaviors are encountered" (2001, 11). Hence, when I refer to self-injurious behavior, I am restricting the discussion to delicate self-injury done by persons diagnosed with BPD. To know how to respond to people who are self-injurious, clinicians need to know what it is. And it is trickier to answer that question than one might think. Definitions of actions falling in this category tend to be question begging, as this essay will suggest. Alderman (1997) summarizes self-injurious behavior as acts that are done to oneself, performed by oneself, physically violent, not suicidal, and intentional and purposeful. The literature distinguishes between delicate, or superficial, and severe self-mutilation, which is defined as "the deliberate infliction of direct physical injury on one's own body. . . that involves cutting, maiming, destroying or altering a part of one's body in a socially unacceptable fashion, and [which] may result in permanent disfigurement" (Parrott and Murray 2001, 317).
Causes of self-injury are also unclear. The most commonly supported explanatory theories are that such acts are kinds of ritual, symbolic expressions, or tension relieving (Zila and Kiselica 2001). Ross and McKay (1979) offer an array of possible causes of self-mutilation including ritual and symbolism, sex, regression, existential statement, manipulation, risk taking, attention seeking, retaliation, frustration, depression, tension relief, inappropriate communication, self-punishment, and low self-esteem (listed in Zila and Kiselica 2001). Diana Milia places self-injury in the "context of cycles of creation and destruction inherent within the creative process" and argues that its healing potential arises out of transformative elements that parallel ritual and other creative processes (Milia 2000, 12). Another theory posits self-injuring acts as an externalization of a woman's fears of being a passive victim of bodily attacks. On this view, fears grounded in a female physiology that is experienced as unruly and particularly vulnerable to invasion are defended against by being the one in control of the harm (Cross 1993). In general, the better attempts to understand cutting and other self-injuring activities view self-injury as employing a form of "default" rationality. On this view, what the person does is rational given her history and the way she views the world, but she acts in ways that are inconsistent with norms for living a flourishing life. As a response to trauma, cutting and other forms of self-injuring are highly adaptive responses. For example, Janice McLane (1996) argues that self-mutilation allows a trauma victim a "voice on the skin" when she is otherwise feeling silenced. On this view, the cutting says what the woman cannot put into words. The body, then, is being used to communicate something that is difficult or impossible to articulate in conventional modes (Crowe and Bunclark 2000; Milia 2000, 76; Miller 1994).
I want to suggest a way of thinking about self-injury that takes seriously its potentially destructive aspects while situating it in a broader discourse of body modifications where the body is being used as a text. To say that the body is text is to suggest that the body, like other mediums of communication, must be interpreted and that its meanings are not given or inevitable. "As a field of interpretive possibilities, the body is a locus of the dialectical process of interpreting anew a historical set of interpretations which have already informed corporeal style. The body becomes a peculiar nexus of culture and choice, and 'existing' one's body becomes a personal way of taking up and reinterpreting received gender norms" (Butler 1987, 133-134; see also Bordo 1989). On this view, one of the texts by which we communicate and engage in mutual meaning-making is the body. This way of framing self-injury raises questions about the role popular culture and psychiatry play in imbuing some acts as fashionable, others as transgressive, [End Page 2] and still others as pathological. It also brings into focus the increasing treatment of the body as a commodity and complex attitudes people have about bodies. My aim is to open up a space for clinicians to be able to respond to a patient who is self-injuring in a morally grounded and therapeutically effective way, drawing upon explanatory theories like the above to some extent but not letting them stand in for the hard work of interactive patient-clinician communication. Treatment is unlikely to be both ethical and effective until more attention is paid to these patients' own views of their behavior (Miller 1994). The task for clinicians—both a therapeutic and moral one—is to find out what, if anything, the patient means by the signs with which she communicates.
Meaning-Making and Responsibility
It is widely recognized that how we experience the world is shaped by our conceptual scheme. This observation has led some philosophers as well as some clinicians to take the further step of claiming that what we believe is true—what we count as knowledge—is (at least partly) determined by our conceptual scheme. On this view, in forming our beliefs—what we take to be true—we are not just passively impinged upon by an independently structured world but instead, through our conceptual scheme, we in some sense construct our representations of reality. The idea is that knowledge is not determined by the nature of things (Hacking 1999, 6); or that what we count as knowledge is always, to some degree, mediated by the particularity of knowers (Code 1991); or that any division between natural kinds and social production of those kinds is a priori indefensible (Gillett 1999, 73). It is important to note that a claim that something is socially constructed does not commit one to relativism, although a full discussion on this point is beyond the scope of this paper. It does, however, lead to the idea that how we interpret things is not independent of the social milieu in which beliefs, ideas, and values emerge, and that what we perceive, when we interact in the world, is always already mediated by norms and practices. Many clinicians are keenly aware that their perceptions, interpretations, and responses to patients are shaped by larger social and cultural contexts as well as value-laden theories of health and rationality. But it may be difficult to see how ideas about social constructionism can be applied to people who engage in self-injury. Still, I believe that that framework is illuminating in that it allows us to reorient a discussion of ethical responses to such cases. To provide a framework for ethical responses to, and interactions with, people diagnosed with BPD who self-injure, I draw on two concepts from theories of meaning: signification and uptake.
I'll start with signification. But first let me say something about body communications, because that is the domain of inquiry. Traditional philosophical analyses of communication focused primarily on speech acts and paid little or no attention to nonlinguistic signs. Critics, however, have argued that that way of conceptualizing communication is too narrow and that we employ numerous other modes of communicative interaction. We communicate through styles of dress, for example, through body "language," smoke signals, and with gift giving. Each of the various modes of communication raises ethical questions about norms for communicating with one another. To foster respect, friendliness, and community, communicative ethics must make a place for "gestures that bring people together warmly, seeing conditions for amicability: smiles, handshakes, hugs, the giving and taking of food and drink" and other embodied nonlinguistic acts (Young 1996, 129). Clinicians are trained to pay attention to a variety of modes of communication and so are well positioned to apply a communicative ethics where the body plays a positive role.
Now to signification. Signs are composed of a signifier (marks on a page or sounds or movements) and a signified (what those marks or sounds or movements mean). The signified, then, is the sense or meaning inscribed in a term or gesture. The task of a potential listener is to determine whether or not something is being communicated and, if so, to interpret it. The [End Page 3] listener or audience does not do this alone; he relies on linguistic and other conventions to infer meaning. Part of this reliance involves the assumption that the communicator is employing a particular sign because she believes her audience will recognize the intention to communicate and pair it up with the intended meaning. (For example, if I am lost and build three fires in a row, I am doing this because I think that someone seeing them will conclude that I wanted someone to recognize that sign and infer that I need help.) But as W.V.O. Quine argues, conventions do not just spring into being; they are brought into being by the behavior of the parties to a given convention (1960). This means, on Quine's view, that "facts" about behavior are not enough to determine whether a given understanding of that behavior is correct. Consequently, we can conclude that interpretation is required, and interpretation is not a science but, instead, an art. I like the way Grant Gillett characterizes the discursive view of communication, which he says
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locates a person in relation to a sphere of discourse and allows one to identify the position he or she is taking and the subjective relationships holding between the person and the context. These reveal how it is to be that person and what choices for perception and action present themselves in a given situation. This in turn illuminates relationships of power, reveals the content of any significations used to organize behavior, and renders understandable the activity of the person concerned; it is as if one were to successfully locate a person on a map so that you and they both remarked, "Ah, now I see where I am!" (Gillett 1999, 28-29).
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What I think is right about this way of understanding explanation (e.g., a patient's explanation of her self-injuring behavior) is that it situates the communicator and audience in a discursive field in a context of power relations. Yet the greater weight of explanatory power in interpretation and meaning-making are placed in the hands of the person whose behavior calls for explanation. I will return to these points later.
The body is one kind of text, and the things it does are units of meaning within a discursive field. With my body, I express the idea "I am a woman" through a myriad of signs of femininity that others know how to read. Movements like soft, gentle hand gestures, touching the hair on one's head, crossing one's legs, and tilting one's head are conventional signs of femininity.
But we make mistakes in our interpretations of signs all the time, including mistakes about gender. Signifiers for gender are like signifiers for Santa Claus—although sense-making, neither refers to anything real. In fact, signification necessarily relies on the construction of a metaphysics that disguises the arbitrariness of its own processes (see Derrida 1974, 12-14; 1981, 30-32). 1 That is, signs get their meaning from their relation to other signs. We rely on conventions of meaning to communicate with one another, but we are too often seduced into thinking that those conventions are reliable. As Gillett says, "it is clear that the realm of discourse is not only an interpersonal realm but also that it cannot be understood without paying some attention to its social and cultural context" (1999, 31). For example, Marilyn Frye argues that, because linguistic and cultural conventions equate women's anger with bitchiness, hormonal changes, cuteness, or irrelevance, women's anger at moral injustices done to them do not get taken seriously and respectfully; instead, cultural norms allow men to minimize, trivialize, pathologize, mock, and ignore women's anger. "As a social act, an act of communication, [women's anger] just doesn't happen" (Frye 1983, 89). When interpreting another's signs, then, we need to be skeptical about cultural imperatives to appeal to conventions that close off alternative meanings or that impose meaning in ways that rob the speaker of her voice.
In interpreting what I will call body signifiers, the first thing you need to ask is whether the signifier has any meaning (that is, is it a sign?). If you determine that you are picking up a sign, your task is to interpret it. Even here, we can make mistakes. Consider an act of burping. In our culture, burps generally are not taken to be "saying" anything. But cultural meanings of the burp vary, which suggests that even knowing when to take seriously a signifier is sometimes complex. We can also err by assuming a signifier has meaning when it may not. Contrast my friend's utterance "one strawberry ice-cream, [End Page 4] please" with the signifier "butterfly tattoo" on her left breast. I might ask why she ordered ice cream, but her answer is likely to satisfy me without my needing to probe for more: she just likes it; it is a matter of taste. The tattoo might be a bit more difficult for me to appreciate; the answer "Tattoos look cool" is a matter of opinion that I may find harder to wrap my mind around. But if I were to push her on the meaning of tattooing in her life, I seem to be assuming that tattooing is not like eating ice cream—a matter of taste—but that it signifies something that requires further explanation. When I decide that signifying coolness is not enough of an answer, I may be looking for deeper meaning that just is not there. But as I have said, we do not make decisions in a cultural vacuum about whether, in a given situation, to accept the relativity of taste or, rather, to press for further explanations: cultural norms influence our interpretations and responses to others' signifying acts.
Now to self-injury. The going wisdom about self-injury is that the person engaging in such acts is trying to say something. My first point, then, is that that general assumption should not be made a universal. Research suggests that some self-injury may be merely a response to physiological stimuli, so not all self-injury has meaning. But second, interpretations of self-injurious acts tend to appeal to a restricted domain of meaning that assumes an underlying psychological anguish in the actor. Although difficult for me to imagine, I believe it is logically possible for someone to enjoy the experience of watching blood drops form on her arm after cutting herself—and for her to hold no other meaning than an aesthetic one. But meaning making is cultural and communal, and an assertion that one's self-injurious act is merely aesthetic may not be enough for others to let the matter rest. We draw on values and beliefs when interpreting signs, but what warrant do we have for aligning a given value or belief with a particular signifier? When we interpret signs written on the body, we must be skeptics with respect to cultural and linguistic norms. When a person is expressing something by cutting or burning herself, we need to remain open to what she may—and may not—be saying. We need critically to attend to the conventions we draw upon to interpret such signs, and to question the cultural norms that delineate when it is and is not acceptable for a person to injure herself with the goal of giving herself aesthetic pleasure. In the next section, I illustrate how complex the matter of body as text can be.
Situating Self-Injury
The deployment of the body as a text is not unique to those with personality disorders. Body modifications can represent aesthetic, religious, or political values. These days, people tattoo themselves, get body piercings and penile enhancement, color their hair purple, lighten (or darken) their skin, and go on starvation diets. Historically, religious people have fasted, flagellated themselves, and discovered stigmata as signs of deep conviction. Lakota people have practiced sundance rituals. Protesters and laborers have gone on hunger strikes. In all these cases, the body is being used as a text. And in all cases, some degree of risk taking and pain are involved. But interpreting the various signs is messy and complicated indeed. Is tattooing, for example, a fashionable form of self-expression or a sign of pathology (Inch and Huws 1993; Sanders 1989)? Let's consider an array of intentional actions that bring about body modifications, all of which involve some degree of risk and pain.
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1. Tattooing
2. Body piercing
3. Surgical implants
4. Scarification
5. Pigmentation changes (skin lightening or tanning)
6. Radical dieting
7. Hunger striking
8. Fasting
9. Stigmata inducing
10. Cutting and burning2
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Several points emerge from this brief look at body modifications. In each kind, to understand what is being "said," we have to consider not only the cultural norms that shape meaning and interpretation, but also the individual communicator. What is being communicated and how it is meant to be received cannot be easily identified. [End Page 5] For example, there are theories about the cultural meanings of tattooing and scarification, but they offer hypotheses of general public meanings that may not be applicable to given individuals. A person with a tattoo may not be clear what her intentions are with regard to the tattoo, or she may not intend to produce any effects on others. Many kinds of body modifications are imitative and, although meanings are constructed (often post hoc), a participant may not intend to say anything other than a reflexive "me too." Note, too, that the question "Why did you do such-and-such an act of self-injury?" can be answered in terms either of explanation/motive or of meaning/intention to communicate, and this ambiguity creates its own problems in interpretation. If I offer an explanation in response to your "why," but you continue to seek for a deeper meaning, which of us should decide when the question has been answered? When ought an answer be sufficient to satisfy others? I also observe that these actions can be grouped in various ways.
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The first five are "amateur or professional," whereas the last five are "self-injuring."
The first six are "aesthetic," the next one "political," the next two "religious," and the last one "pathological."
The sixth and the tenth are "pathological" and the rest are "socially acceptable."
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Furthermore, some kinds of body modifications do not lend themselves to any of the above groupings in an obvious way. Amputation for nonmedical reasons seems to be sought for reasons of identity rather than purely aesthetic or other reasons. For example, one person says "My left foot was not part of me" to explain the desire for amputation (see Elliott 2000.) Penile enhancement may also be sought as a matter of identity or self-worth. Are body modifications that are identity affirming still self-injuring? Why would one kind (penile enhancement) be socially acceptable and the other (amputation) be pathological? Complicating these groupings even more is the claim by some tattooed people that their tattoos are an expression of identity (Bell 1999; Sanders 1989.) Do these different identity-conferring "self-injurious acts" have something in common that we are not understanding?
It is not clear what justifies these groupings. Clearly, attitudes about what is proper and acceptable to do with one's body play an important role in interpretations of body signs. In tattooing, for example, even if the signified is about belonging, the tattoo is part of how its signification gets interpreted. We signal belonging in many ways: T-shirts, bumper stickers, and flags, for instance. When the signifier is written on the body, its materiality is itself important. The chosen mode of signification, therefore, is part of the signified. Yet it is unclear what criteria we use in assigning sense and meaning to these various body signs.
As a culture, audience responses to this variety of body modifications are sometimes tolerant, other times oddly intractable. If we view a body alteration as aesthetic, political, religious, or identity conferring, we may negatively evaluate it but eventually seem to drum up toleration. In those cases (students with nipple piercings, colleagues who fast), we make an effort to be tolerant even when we do not ourselves appreciate, understand, or endorse the sign. This is even true of the excessively thin models who evoke admiration and envy (but not judgments of pathology) in virtually everyone but health experts. What is so objectionable about cutting or burning that it cannot elicit tolerance like (for instance) scarification of some African tribal peoples?
Blood letting has ancient communal roots that merit examination in this context. Zila and Kiselica note that ritual and symbolism is one of two most commonly supported theories about causes of self-injury (the other being tension relief.) Those authors, drawing on earlier research, note that "Ross and McKay (1979) explained ritual and symbolism in descriptions of self-mutilation that are laden with religious overtones and symbolism. Favazza and Conterio (1989) concurred with this theory, citing frequent references to the need to atone for sins by those who self-mutilate. Himber (1994) found a common theme of self-purification among these individuals" (Zila and Kiselica 2001). There are many reasons a community engages in blood sacrifice, including pacification of afflicted spirits (Turner 1967) or payment of homage, atonement, or purification to [End Page 6] deities (Burkert 1983). I will discuss one theory of sacrifice that may illuminate some self-injurious behavior.
Milia argues that, although sacrifice and symbolism have recognized cultural currency, one purpose of sacrifice is to draw boundaries between good and bad violence and to reestablish order for a community. Sacrifice, then, is a special kind of violence that the community approves of and controls through ritual and symbolism (Milia 2000, 17). The need to create order out of chaos and thus reassure requires that violence and blood letting be further designated as good or bad kinds:
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Just as violence has been split into good and bad types—that which is sanctioned for the purpose of maintaining societal order and that which is unlawful—blood has also been classified in opposite types. . . . The dual nature of blood becomes apparent as its presence represents the life force, and its spillage heralds the draining away of life. (Milia 2000, 18)
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What is striking in Milia's account is the suggestion that the transformative quality of sacrifice and its symbolism is in its duality. "Symbolically, the sacred victim [of sacrifice] comes to represent that which is both evil and transcendent of evil. The ritual of sacrifice forms a bridge to transcendence of sin, and in this way accomplishes purification" (2000, 17). This analysis, then, suggests that the sign may not be just one thing—it may contain paradoxical concepts—and clinicians will need to look for contradictory meanings (and not push for an artificial or early resolution.)
Still, the question remains why body modifications are given the meanings they are. Milia suggests that, even when mainstream culture views some body modifications as socially deviant or transgressive, they are not viewed as pathologies if they are meaningful at least to a subculture. Tattooing, scarification, and body piercing are signs that transform self-injuring wounds into aesthetic expressions. This transformation purifies its violence and reenacts rituals of human sacrifice at a higher level of symbolism (Milia 2000, 26). Cutting or burning, however, when done alone and in secret, fall outside culturally acceptable meanings of aesthetic, ritual, or political significance (Milia 2000, 43).
Furthermore, contemporary culture has generated panic and distrust about bodily fluids, displacing fears about external threats onto the secreting, leaky body.
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The rubber gloves the Washington police force insisted on wearing before touching the bodies of gays who were arrested at recent AIDS demonstrations in Lafayette Park across from Reagan's White House; the sexual secretions in contemporary American politics where presidential candidates, from Hart to Celeste, are condemned out of hand by a media witchhunt focussing on unauthorized sexual emissions; and routine testing, the Reagan Administration's bureaucratic term for the mandatory policing of the bodies of immigrants, prison populations, and members of the armed services who are to be put under (AIDS) surveillance for the slightest signs of the breakdown of their immunological systems. (Kroker and Kroker 1987, 12; emphasis in original.)
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The distinction between good and bad body modifications, therefore, may indicate cultural responses to perceived evil or impending danger. Nevertheless, as Milia suggests, the distinction really seems to amount to a difference between what the culture understands and does not understand (or between what it is willing to understand or not).
Finally, although I am not arguing for a new taxonomy for BPD, I do think this broader view of body modifications suggests that self-injury (or self-mutilation, for that matter) does not pick out a persuasive set of factors for pathologizing body-related actions of someone diagnosed with BPD. Historically and cross-culturally, then, there is a variety of potentially harmful body modifications, and they intersect with cultural norms in complex and varied ways.
The next section situates self-injury more broadly in the context of cultural, political, and economic attitudes about the body.
Commodity/Body/Sign
In this section, I consider the possibility that some self-injurious actions have meaning, but argue that that meaning may indicate cultural, rather than individual, pathologies. Where body modifications are concerned (cutting and burning included), self-injuring may signify a reaction [End Page 7] against dehumanization (Milia 2000, 47). One theory of self-injuring suggests that, by harming the body, the individual highlights a distinction between body and self (Zila and Kiselica 2001).
The typical self-injurer is female, adolescent or young adult, single, from a middle- to upper-middle-class family, and intelligent (Favazza and Conterio 1989; Suyemoto and MacDonald 1995). One study found that the difference between patients with BPD who engaged in self-mutilation and those who did not could not be explained by different histories of abuse or by levels of dissociation (Zweig-Frank et al. 1994). Rather than looking for meanings that go back to childhood experiences, clinicians might explore ways that the culture produces such expressions. Like tattooing and other accepted forms of body modification, cutting and burning may be imitated actions and, in fact, research suggests that social contagion may be a factor in self-injury (Zweig-Frank et al. 1994). But instead of it signifying a contagion of individual pathological behavior, it may signify those individuals' locations in social and economic systems. Because most of those who delicately self-injure are female, I focus here on female bodies.
Robert Mitlitsch (1998) argues that late capitalism has amplified a commodification of the body. The sign-value of the body has increasingly come to hold aesthetic promise as well as use/exchange value. Commodification, then, performs the cultural labor of signification. As the global economy becomes increasingly consumer oriented, and the body is conceptualized as another commodity to market and remake as desirable, the body is susceptible to objectification as never before (for just one example, see Morgan 1991).
Women's bodies are commodified specifically in sexual ways. (Women's bodies are also commodified in the service of reproduction, but I do not delve into that issue here.) Women still internalize cultural views that their primary value is in evoking sexual desire and delivering up sexual pleasure. Normative femininity includes standards of beauty that picture women of value as impossibly thin and attractive. Whether or not an individual woman resists these norms, she must objectify herself to evaluate herself and decide how to respond to those norms.
The distress expressed by women diagnosed with BPD may not be unique, but rather may reflect a more general experience of being female in our culture (Miller 1994). The female body in literature and popular culture has been both extolled and despised, eroticized and reified and yet viewed with disgust and distrust. Female being is conceptualized and represented as a being to be perceived (Bartky 1990; Berger 1972; Bourdieu 2001; Kaplan 1983). Body image, for many women, is fragmented into parts (a pretty waist, an ugly nose) rather than as a whole, embodied self (Cross 1993). This claim is borne out by research on attitudes self-injuring women have about their bodies: "More than half of the [self-injuring] participants in Favazza and Conterio's (1989) study reported the presence of troublesome sexual feelings: 34% hated their breasts, 56% strongly hated having a pelvic exam, and 10% indicated they would be better off without a vagina" (Zila and Kiselica 2001). But these findings are not specific to those who self-injure. Body loathing is not surprising given cultural attitudes about women's bodies.
Furthermore, female physiology contributes to women's experiences of their bodies as discontinuous and alien. Partially internal genitalia, with their ambiguous and mysterious workings, relatively abrupt changes in body contours during puberty and pregnancy, and menstruation with its pain and messiness give rise to experiences of embodiment that are ambivalent at best. Female physiology intersects with a culture that, in particular, commodifies women's bodies, overdetermining a metaphysics of the body as object.
In the context of an economy and culture where body commodification and objectification proliferates, women become increasingly alienated from their bodies (see, for example, Emberley 1987). Hence, the need increases for women to experience their bodies as real. This can prompt a (perhaps unconscious) transgressive response in an attempt to real-ize the body as "one's own." (Trangression is used here in the cultural sense, rather than in the sense of sin and evil, and is sometimes used to praise acts that violate repressive norms. For a discussion on an ethos of transgressive acts as acts of resistance to socially controlled and disciplined bodies, see Passerin-d'Entreves 1999; see [End Page 8] also Marchak 1990). Judith Butler, drawing on Mary Douglas's theory of the body, says that whenever boundaries of the body are established, the taboos about the limits of those bodies become naturalized (made to seem natural) (1990, 131). And Douglas, in a passage that resonates with Milia's analysis of the duality in sacrifice, writes that "ideas about separating, purifying, demarcating and punishing transgressions have as their main function to impose system on an inherently untidy experience. It is only by exaggerating the difference between within and without, above and below, male and female, with and against, that a semblance of order is created" (Douglas, as quoted in Butler [1990] 131). The point is that what constitutes the limit of the body is signified by taboos and anticipated transgressions.
Self-injury is a taboo because it transgresses an imposed boundary that seems, to us, natural and given—the boundary between body and self, between material and immaterial, and between subject and object. As the body is increasingly destabilized and disposable, it requires more and greater transgressive acts to produce the appearance of substance. Cutting and burning, then, might be understood as an attempt to "own the body, to perceive it as self (not other), known (not uncharted and unpredictable), and impenetrable (not invaded or controlled from the outside)" (Cross 1993). Still, this interpretation may not be what an individual woman means when she cuts or burns; asked why she cuts herself, an individual may not explain things this way. And clinicians may still want to convince her not to resist commodification this way, arguing for better ways to "produce the appearance of substance." My point is that the audience is unlikely to learn the meaning of the sign in a given situation unless it learns to listen differently.
Communicative Ethics When the Body is Text
Clinicians are often at a loss to understand the actions of individuals who self-injure. Many find it difficult to talk about the self-injury in a way that allows the patient a role as interpreter of her own signs (Favazza 1996; Himber 1994). "Ross and McKay (1979) found that only after conceding that they did not understand self-mutilation were counselors then able to suspend clinical judgment and allow the young women to explain their behavior" (Zila and Kiselica 2001).
This brings me to the second concept in communicative ethics—that of uptake. 3 An understanding of this concept can help clinicians talk with their patients about self-injury with the openness I advocate. Uptake is a linguistic concept introduced by J. L. Austin (1975) to characterize the role of the listener in securing the meaning of a speech act. According to Austin, when the listener receives another's speech act with the conventional understanding, the listener has given the speaker uptake. For example, one cannot be said to have warned an audience unless that audience hears what one says and takes what one says in a certain sense, say as an alarm, an alert, or a threat (571). Another example is that of promising: my promise to you can be said to be successful when you understand my speech act as one in which I place myself under obligation to you.
But many of the conventions of language are bound up with social conventions and power relations, which can elide the voice of the disempowered. So giving uptake cannot simply be a matter of relying on norms and conventions of communication. Frye, expanding on Austin's idea, discusses uptake in terms of anger: "Being angry at someone," she writes, "is somewhat like a speech act in that it has a certain conventional force whereby it sets people up in a certain sort of orientation to each other; and like a speech act, it cannot 'come off' if it does not get uptake" (Frye 1983, 88). Uptake, then, occurs when the second party, listening to my speech act, reorients herself to me and the relation between us "comes off" with an appropriate response. Women, Frye argues, typically do not get uptake on their anger because cultural norms allow men to ignore or trivialize it. Although gender is not the only axis of power—and a straightforwardly binary account of language conventions in terms of gender would be oversimplified—Frye is right to identify patterns of relating that follow structural power relations. A proper response is one that conveys an empathetic attitude toward the communicator or an earnest attempt to understand [End Page 9] things from the communicator's point of view. But it is difficult to empathize with (or just take seriously) people who seem to be very different from us, and societal norms often discourage it; in this way, relying on patterns and conventions may impede, rather than facilitate, understanding.
In giving uptake, we still may not agree with the communicator; we can take others seriously and yet disagree. But when we take another seriously, we also take seriously the reasons that person gives for her actions and beliefs. To give uptake rightly, then, it is not enough simply to receive another's communication with the conventional understanding. We must try to understand what the world looks like from the communicator's position. This may require that we set aside preconceived ideas about value and meaning.
Of course, as deployers of signs, we do not always know what we are trying to communicate or our reasons for communicating something. Still, there is a danger in disregarding a communicator's explanations and drawing, instead, on cultural norms or in assuming we know more about a communicator's meaning than she herself does. Listeners' responses to survivors of the Holocaust, for example, often clutch at a familiar lexicon that wards off the discomfort and fear that arises when hearing about an alien moral landscape (Langer 1991). For example, when Hanna S. says she survived through luck and stupidity, the interviewer protests "No, you were plucky." Langer argues that interviewers of Holocaust survivors override the speakers' interpretations of events out of a desire to preserve preconceived associations between victims of evil and heroic survival. In this context, though, familiar moral vocabulary and norms are irrelevant to a discourse that attempts to give voice to experiences of the Holocaust. The survivors are mining their common and deep memory about their experiences, thoughts, and feelings, but the interviewers have (or make) no cognitive or moral space to accept as real the things they are being told. The interviewer fails to give uptake to the speaker by refusing to grant validity to the speaker's different system of signs. Instead, she explicitly discounts the interpretations given by the speaker telling the story.
We can extrapolate from Langer's analysis to a communicative ethic for clinicians who work with patients who self-injure. We have few, if any, language conventions to lead us through discourse about self-injury in a way that preserves the integrity of the communicator. Without conventions that are appropriate to the specific participants of a conversation, most hearers fall back on familiar conventions rather than charting this new territory.
Another aspect of giving uptake, then, is that one does not impose interpretations and meanings that the (other) communicator is unwilling to receive except through coercion. People in positions of authority (parents, teachers, clinicians) can put pressure on others to acquiesce to their interpretations, and giving uptake rightly requires that we guard against such tendencies. Clinicians, among others, have the ability to silence the communications of the less powerful, and one effective way to do that is to stop a communication from counting as the action it was intended to be (Langton 1993). In other words, relying on the conventions of one's own culture, place, and time may skew a listener's ability properly to give uptake to the communicator. It is true that, in trying to give uptake properly—and by holding meanings open rather than closing them off—a clinician may be left with little common ground by which she can receive and understand another's communications, and that experience can be quite disconcerting—frightening, even. But it is my belief that the communicative struggle, in this situation, is integrally bound up with being an ethical clinician. Genuine understanding is not easy to come by, and we should expect it to call for moral, as well as epistemic, effort.
Communicative Maxims That Guide Giving Uptake
Let me now fill out these ideas a bit more. In analyzing the logic of communication, H. P. Grice introduced principles and maxims for conversation, such as "Do not make your contribution more informative than is required," "Be relevant," and "Do not say that for which you lack adequate evidence" (1989, 26-27). Extrapolating [End Page 10] quite freely from Grice's maxims, I offer five communicative maxims to guide the giving of uptake where the focus of therapy is the self-injurious behavior of people diagnosed with BPD. These maxims are for a restricted domain; they may not apply for other diagnoses or for other identifying behaviors of BPD.
Approach Discussions of Self-Injury with the Principle of Charity
The principle of charity holds that, rather than thinking that what a person has communicated is false, we try to interpret what a person communicates as true. I suggest that clinicians employ this principle when talking with BPD patients about self-injurious behavior. According to philosopher Donald Davidson, a theory of meaning allows us correctly to interpret the communications of others. But we do not yet have an adequate theory of meaning when it comes to self-injurious behavior, so we cannot know a priori what meaning a given self-injurious act has (Miller 1998, 263-273). If understanding a patient involves something like interpretation, then we can either aim for preserving truth in a communicative exchange or for preserving meaning. Davidson's argument is that a theory of meaning ought to adopt the principle of charity as an attitude an interpreter takes before he or she can interpret.
I recognize the contentiousness of suggesting that patients diagnosed with BPD be approached with the principle of charity. Such patients may have cognitive difficulties that hamper their grasp on reality, so readers may question the value of assuming communicator truth in such cases (Gunderson 2001; Kroll 1988). On the other hand, the two main cognitive problem areas for BPD patients—reality testing and thought processes—occur mostly under episodes of stress and seem to be relatively strong and intact otherwise (Goldstein 1995). So let me try to motivate this maxim.
The argument I have advanced concerning self-injury is that it can be located among various body modifications found across cultures. It is unwise to assume a priori that we know what a given signification means. It is important to resist the rush to judgment that a patient's actions are irrational or pathological without exploring the patient's own interpretations and explanations for her behavior. What I am suggesting here, then, is that clinicians should assume that, in the circumstances in question, the patient has beliefs that, by our lights, are true (Miller 1998, 270). What this amounts to is that the clinician hold beliefs constant as far as possible while solving for meaning (Miller 1998, 270). The value in this approach is that it slows down the interpretive process and shifts more of the right and responsibility for meaning-making to the patient. Adopting this principle, then, would create a space for the clinician to interpret with her patient the actions under scrutiny, while allowing the patient to take the lead.
Note that this maxim applies to a very restricted domain: it concerns patients diagnosed with BPD, and only with respect to communications about self-injury. What I am proposing, in effect, is that clinicians bracket off their evaluative skills and capacities to the degree that they are not distracted by judgments about truth value while therapeutic work is being done on the subject of self-injury.
Take a Critical and Reflective Stance toward Your Own Conceptual Framework
Although none of us can step outside of culture altogether, we can evaluate our attitudes, beliefs, and values from a second-order level (Taylor 1989; Frankfurt 1971). Complete objectivity is an unlikely ideal. But clinicians can, and should, think critically about ways in which prevailing norms and values may be influencing their understanding of the world and their ways of being in it. They need to be on guard against subtle assumptions about health, rationality, and good actions that could be misguided in the case of a particular patient and thereby inhibit that patient's ability to heal.
Adopt a Position of Epistemic Humility and Moral Uncertainty about Meanings and Explanations for Self-Injury
Related to the last maxim, this one encourages the clinician to be open to discovery. To do [End Page 11] that, the clinician needs to be somewhat skeptical toward her own confidence level with respect to general meanings about self-injury. She should suspend judgment to the degree she is able without jeopardizing the short-term physical safety of the patient. Clinicians must be concerned about imminent danger, so this maxim cannot always be applied. But taking a longer range view, this heuristic allows the clinician to work with the patient in exploring meaning and to participate in meaning-making that is not prematurely closed off.
Recognize That the Patient, Too, May Bring Assumptions about Her Behavior That Are Culturally Inflected
This is, perhaps, a call for balance between adopting the principle of charity, on the one hand, and taking the patient's point of view as the final one, on the other hand. Taking an explanation or a meaning as "true," in this case, does not commit the clinician to any particular theory of truth. Patients may be believed about their own interpretations, but clinicians and patients together may want to unpack patients' conceptual framework regarding self-injury. Patients are likely to pick up the idea that people who self-injure are pathologically demented, and that attitude may be expressed by the patient in therapy, but it is important to try to identify whether the patient is distressed by her own behavior or whether she just believes that she ought to be.
When Asked to Give an Interpretation, Offer Disjunctive Ones
Sometimes a patient will ask the clinician for assistance in understanding her actions, and sometimes the clinician will want to offer alternative interpretations to the one the patient is offering. In the spirit of openness and a commitment to patient autonomy, clinicians should offer an array of interpretations so that the patient can explore various possibilities to see which best fits. Or, the patient and clinician may brainstorm together about possible meanings. The point is not to impose an interpretation that the clinician thinks is correct, and not to close off opportunities for discovery or new knowledge. When offering disjunctive possibilities for interpretation, the clinician may need to avoid simple either/or statements, because patients with BPD are already prone to thinking in dichotomous extremes and need to be encouraged to think in more complex terms.
The aim of these maxims is to preserve the integrity of the communicator vis-à-vis her unfolding understanding of her self-injurious behavior. The value in it is that it facilitates greater understanding of the patient's experience. But clinicians may assent to the usefulness of such a communicative ethic while remaining unconvinced of its force. I now turn to questions of justification for such an ethical stance.
Giving Uptake as an Obligation
Elsewhere, I have argued that giving uptake is a virtue (cf. Potter 2000, 2002). Let me briefly sketch the ideas of virtue ethics and explain how uptake fits into a general theory of virtue.
A virtue is a state from which a good person feels, makes decisions, and acts rightly according to what the situation calls for. Virtues are essential to living a fully flourishing life. Virtues of character such as friendship, justice, trustworthiness, industriousness, and integrity enrich us personally and help us live with others cooperatively. Some virtues are corrective, in that they draw us away from human tendencies toward such things as selfishness or laziness. The virtue of giving uptake rightly is a corrective one. All of us are liable to be, at times, dogmatic and overly confident about our own beliefs, values, and interpretations. We tend to become entrenched in our own world views and dismissive of others whom we take to be wrong. We may try to impose our views on others and to dominate them in communicative interactions. Because of these problems, John Stuart Mill (1978) urges us to take other points of view seriously so as to foster freedom of thought and speech and to increase truth. Mill characterizes this dialogical problem as a tendency in people to be unwilling to entertain opposing points of view. A disposition [End Page 12] to give uptake rightly, then, can serve as a corrective for people who respond to others with arrogance or whose feelings of certainty lead them to discount the views of others.
Many of the virtues have a scope by which they can be identified. The scope of courage is feelings of fear and confidence about frightening things; the scope of temperance is bodily pleasures and pains of touch and taste. The scope of the virtue I call "the disposition to give uptake rightly" is dialogical responsiveness and openness in the context of plurality and power relations.
All of us need to cultivate the virtue of giving uptake; the virtues in general are central to being a good person and living a good life. Living a good life is not only an individual task; we need to help bring about the conditions for a good life for others as well. Virtue is social and communal, and living well is not just a goal for you or me, but for all of us together. Giving uptake is a crucial corrective to our tendency to be overly committed to prevailing norms and conceptual schemes. Being entrenched in a conceptual scheme or cultural milieu impedes our ability to communicate across differences, to expand our body of knowledge, and to foster democratic practices.
Clinicians, too, have an obligation to become the sorts of persons who will give uptake rightly. The primary obligation of clinicians, as for all medical practitioners, is to promote health and/or healing. To that end, professional codes of ethics charge clinicians with a duty to uphold values common to all medical practice, including respect, autonomy, dignity, benevolence, and nonexploitation (Radden 2001). These values are important in that they set constraints on clinician-patient interactions so that relief from patient suffering and distress is facilitated as much as possible and not exacerbated or frustrated by a damaging therapeutic relationship. These values and duties of medical practice are part of a larger moral landscape in which we recognize that all human beings have certain basic needs that must be met in order to live a life of minimum suffering, and that some of those needs are in the moral domain. Most clinicians, I believe, are committed to professional standards of ethics. But, because we are culturally shaped, clinicians do not come to encounters unmediated. All of us perceive, reason, and evaluate through conceptual schemes that are embedded in socially situated norms. So for clinicians fully to embody the values and commitments of medical practice, they need to extend their ethical framework. Learning to give uptake is an instance of ways that clinicians need to stretch themselves morally and, because uptake is a virtue, it is part of what is involved in living well.
Clinicians need to give uptake to patients who self-injure, then, because it is part and parcel of treating others with respect and dignity. Giving uptake need not assume that self-injury itself is a communicative act. What clinicians need to give uptake about is the patient's perspective on her self-injurious acts. For the reasons I have argued, it is particularly difficult to understand self-injurious behavior and to know how to situate it in relation to other body modifications. When confronted with patients who self-injure, clinicians are in need of a corrective to the tendency to interpret a priori the meanings of such significations. Without the virtue of giving uptake, clinicians run the risk of silencing or distorting the communications of their patients.
There is a second reason clinicians are obligated to develop ethical responses to patients who self-injure by cultivating a virtue to give uptake, and that reason has to do with the relation of uptake to trust. Noting that a central component of any ethic is communicative, I point out that failure to give uptake can impede patient trust in the clinician. Good communication both requires and fosters trust, and trust is a crucial moral dimension of the therapeutic relationship. Being trustworthy requires that we take care not to exploit the vulnerability that comes from placing trust in us or needing care from us (cf. Potter 2002). Patients are vulnerable to the power, knowledge, and expertise that comes with being a clinician and may be concerned about being misunderstood or interpreted in ways they disagree with. Giving uptake is also morally important, then, because it fosters trust when patients experience their clinicians as sensitive to the vulnerability of their patients; being trustworthy, because it is nonexploitative and nondominating, [End Page 13] facilitates therapy. But it would be a mistake to cast trust in purely instrumental terms. Although it is true that proper trust may foster healing, being trustworthy is intrinsically good. Like friendship, trustworthiness needs no further justification, even though benefits may derive from it. It is also a mistake to construe therapeutic interests as separate from ethical ones. Both are concerned with helping others live as flourishing a life as possible. When aims conflict, therapeutic healing must build into the relationship a way to mend broken trust and restore moral equality (cf. Potter 1996).
There is a third reason for clinicians to take seriously the claim that a good clinician gives uptake to her patients, and that is an epistemic one. Responsible knowers make efforts to perceive and to understand correctly. To the extent that our own conceptual schemes inhibit our ability to grasp meanings other than ones we are already prepared for, we may miss important truths. Clinicians, because they are trained to perceive pathologies and to interpret patients' behavior in ways that are consistent with prevailing norms for femininity, health, rationality, and propriety, may inadvertently impose interpretations on their clients. To do this, though, runs the risk of ending up with mistaken belief. To be a good healer, the clinician must have accurate knowledge. To gather correct knowledge, the clinician needs to listen to the patient in ways that allow for new knowledge to emerge.
Cultivating the virtue of giving uptake, then, can facilitate clinician understanding of the difficult and complex behavior of delicate self-injury engaged in by people diagnosed with BPD. This virtue is only one among many that clinicians need to treat patients in a therapeutically and ethically grounded manner. Compassion, integrity, justice, intellectual virtue, and others are also central to being a healer and therapist. Virtues are not the special provenance of clinicians, either: we all need the virtues. It is also true that being virtuous will not, in itself, heal the mentally ill. Patients diagnosed with borderline personality disorder who self-injure may need to form contracts, be prescribed medications, and so on. But part of knowing how best to treat a particular self-injuring patient is coming to an understanding of what such behavior means to that patient, and to do that requires an ethics of communication, a central feature of which is the virtue of giving uptake.
Acknowledgment
I would like to thank Jennifer Radden, John Sadler, Jerry Kroll, Robert Kimball, and three anonymous reviewers for giving helpful suggestions and criticisms on earlier drafts.
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Endnotes
1. See my "Liberatory psychiatry and an ethics of the in-between" for a discussion of the implications of postmodernism for psychiatry.
2. Some of these body modifications may be considered ornamental (body piercing in the United States; scarification in some African tribes), and some of these body modifications serve to identify group memberships (scarification may signify a particular ethnic identity; tattooing may signify belonging to a self-chosen community).
3. This section draws on my earlier work (Potter 2000).
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