Holding onto the Social Context : Issues of Identity and Power in Personality Disorders

Marsh, Shannon and Bourne, Katy and Hodge, Suzanne (2025) Holding onto the Social Context : Issues of Identity and Power in Personality Disorders. PhD thesis, Lancaster University.

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Abstract

This thesis critically examines how the diagnostic construct of Personality Disorder interacts with the sociocultural context in which they are situated. It comprises three sections: a systematic scoping review, an empirical research paper, and a critical appraisal. The scoping review mapped 61 publications exploring the intersection of personality disorders (PDs) with gender, sexuality, and relationship-diverse identities. Findings revealed a narrow, predominantly US-based methodological landscape focused on prevalence and diagnostic trends, signalling the need for group-specific systematic reviews. Conceptualisations clustered around internal predispositions, sociocultural factors, or diagnostic bias, underscoring the necessity of situating assessment within its sociocultural context and revising diagnostic tools. In many cases, PD diagnoses appeared inappropriate once systemic oppression, discrimination, and trauma were fully considered. Building on these findings, the empirical study employed a constructivist grounded theory-informed approach to investigate how power is enacted and experienced in the care of individuals diagnosed with borderline personality disorder (BPD). Analysis of nine participants’ accounts produced a conceptual model showing how macro-level discourses and everyday clinical practices intersect to shape identity, access to care, and wellbeing. The diagnosis itself emerged as a form of epistemic power, legitimising stigma, undermining credibility, and constraining therapeutic possibilities. Recommendations include structural reform and a fundamental shift in service responses to those diagnosed with BPD. The critical appraisal reflects on theoretical, methodological, and reflexive considerations underpinning the research. Across all sections, the thesis highlights the entrenched harms of PD diagnoses, exposes the systemic reproduction of stigma and marginalisation, and calls for relational, context-sensitive, and identity-affirming models of care. It further contends that dismantling the PD construct may ultimately be necessary to overcome the inequities it perpetuates.