The Politics of the Borderline Brain: Dialectical Behaviour Therapy and Neoliberalism in Swedish Psychiatry
This paper considers the role of the medical humanities in making visible – and critiquing – the relationship between political economy and the neuro and psy disciplines. Drawing on the history of Dialectical Behaviour Therapy (DBT) in Sweden, the paper attends to the ways in which the present neurobiological model of mental illness, which places pathology firmly within the individual, obscures the role of socio-economic forces in generating psychological distress.
DBT was developed in the 1980s to treat suicidal, primarily female, patients with Borderline Personality Disorder (BPD) and subsequently introduced in Sweden in 1995, at a time of profound socio-economic change whereby the social-democratic welfare model was replaced with a neoliberal framework. This included a sweeping reform of psychiatric care which saw the number of beds dramatically reduced. DBT was presented as a cost-effective treatment for BPD patients, who were overrepresented in inpatient populations.
Within DBT, the Borderline patient was framed as the ultimate anomaly of the new liberalism: a young woman who needed stability, permanence, and social support, and who reacted irrationally and impulsively to her surroundings. DBT would teach this patient the skills to ‘help herself’ in a society where the need for social support was increasingly construed as contrary to both good character and good health.
This narrative was given a neurobiological foundation by Åsa Nilsonne, who co-authored the first Swedish language manual on DBT. Nilsonne drew on neuroplasticity research to argue that repeated practice of ‘emotional regulation’ resulted in structural neurological change enabling individuals to become better at managing psychological distress.
The language and framework of DBT obscured socio-economic factors from the illness model, endorsing the neoliberal language of individualism, responsibility, and efficiency. This language was further entrenched through a biologisation of the symptoms of BPD, which located both problem and solution within the individual’s brain. By learning emotional regulation, the Borderline patient could manipulate her brain to function effectively in a society that increasingly valued individual responsibility and autonomy over social support.