Lester, R. J. (2009). Brokering authenticity: Borderline personality disorder and the ethics of care in an American eating disorder clinic. Current Anthropology, 50(3), 281–302. https://doi.org/10.1086/598782

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Miller et al. (2025) published a fascinating article on their research, which included qualitative data from 14 of the participants who were diagnosed with both borderline personality disorder (BPD) and an eating disorder (ED). Before discussing their findings, they elaborate on the fact that hospitalization, self-harm, and suicide attempts occur more often in patients with both disorders rather than one or the other. As a result, it is beneficial for clinicians to gain insight into their experiences, thereby expanding treatment options in an eating disorder rehabilitation center. 

They found five central themes throughout their qualitative data collection:

- The central role of emotions in the relationship between EDs and BPD.
- Perception of BPD in ED maintenance and treatment. 
- Relational dynamics faced by patients during treatment. 
- A feeling that treatment was “never enough.” 
- The importance of addressing ED and BPD symptoms simultaneously.

Lived Treatment experiences: The Complexity and Clinical Impact of having both an Eating Disorder and Borderline Personality Disorder.

Clinicians are attempting to both diagnose and treat clients accurately while working within the American Healthcare system to ensure that their clients receive continued care. One researcher, Lester (2009), found that they worked in an eating disorder clinic and observed the difficulties that their clinicians faced. 

Some challenges include:

- The resident needs to be sick enough but also appear genuine in their recovery for insurance companies to provide continued support. 
- Having enough resources to continue care even when at a healthy weight.
- Documenting behaviors so that they appear less borderline.

Ethical Concerns of Care and the Impact of Clinical Diagnostics for BPD Patients with Eating Disorders

All of the researchers' participants believed that their ED was merely an outlet for their BPD. Since BPD makes one feel out of control, the ED, one said, “gives you drive, it gives you… a goal… With BPD, you feel like you're so out of control all the time” (Miller et al. 2025). Not only does this provide a priori evidence for individuals who may struggle with both BPD and ED–BPD is more likely to arrive first–but it also suggests that BPD is often a force that is very far outside of their control. It is not that they wish to struggle with emotional regulation, indecision, or self-destruction.

Perception of BPD in ED maintenance and treatment. 

One common theme of participants struggling with both BPD and EDs was working in an environment with several others. They were easily irritated and had several interpersonal conflicts (Miller et al. 2025). On the other hand, participants also highly valued their relationship with their therapists. Thus, as often is the case with BPD, if they placed their trust in their therapist and the therapist did not meet their expectations or made a mistaken promise, there was turmoil in the relationship, but also in the participant’s recovery (Miller et al., 2025). 	

Relational dynamics faced by patients with both BPD and ED during treatment.

Currently, there are several ethical concerns regarding care for participants with both eating disorders and BPD and pathology. For instance, there is a high relapse rate for these individuals, who will often struggle with ED behaviors on and off for the remainder of their lives. The Miller et. al. (2025) research offers qualitative insight into the why behind these relapses. All 14 of their participants express their fear of relapse after treatment and acknowledged that they will likely resort to ED behaviors because, without the safety net a therapist provides, they begin to feel hopeless and out of control, so the ED behaviors comfort them (Miller et al. 2025). One participant stated, “I see myself relapsing… so that I'll get referred back to the [ED Clinic] because like I can't be without, like, anything at all… my brain can't compute that, like to just be completely on my own… I don't feel safe.” (Miller et al., 2025). This research shows that there needs to be a change in either the treatment process or the accessibility to treatment. 

A feeling that treatment was “never enough.”

Current research on the comorbidity between both disorders agrees that the eating disorders' pathologies are often a means to cope with emotional distress, and Miller et al. (2025) find this to be true in their research as well. However, they also add that targeting these emotions is critical to treatment. 
One participant interestingly emphasized that binging, purging, or restricting are the only methods that ever provided some form of comfort. Other emphasized the importance of exploring emotions and appreciated the days they had Dialectical Behaviorial Therapy. The aspect they enjoyed the most was the fact that they were able to understand and related to others through DBT, finding a sense of comfort and confidence in emotion regulation. Additionally, one participants discussed how other ED focused treatment did not use emotion focusd langage and instead said, “you eat your lunch” rather than what this participants thought to be more helpful “what are you living or what are you feeling right now” (Miller et al. 2025).


The central role of emotions in the relationship between EDs and BPD.

Similar to Lester's (2009) research, Miller et al. (2025) found that it is essential to target both BPD and ED if the patient is to make a full recovery. These researchers found that by shifting focus to and from both disorders consistently, recognizing the BPD pathology, and holding the belief that recovery means resolving both disorders, improves their chances of recovery. One participant described her experience as that of a whack-a-mole; she would take down an ED symptom, but then another BPD symptom pops up, encouraging certain coping mechanisms (Miller et al., 2025). Lastly, participants emphasized that if one symptom that coexists in both disorders is treated, that does not necessarily mean that there will be improvement in both disorders, especially if you are only looking at the symptoms from one perspective, such as an ED perspective.

The importance of addressing ED and BPD symptoms simultaneously. 


Brokering Authenticity: Borderline Personality Disorder and the Ethics of Care in an American Eating Disorder Clinic

Miller, A. E., Hotte-Meunier, A., Bain, T., Macdonald, E. P., Steiger, H., & Racine, S. E. (2025). A Qualitative Study of the Lived Treatment Experiences of Women With an Eating Disorder and Comorbid Borderline Personality Disorder. The International Journal of Eating Disorders, 58(5), 860–867. https://doi.org/10.1002/eat.24390

A Qualitative Study of the Lived Treatment Experiences of Women With an Eating Disorder and Comorbid Borderline Personality Disorder

In Brokering Authenticity, Rebecca Lester describes how Caroline, a patient in their clinic, struggled for many years with a Binge Eating Disorder and later they found out BPD behaviors. Caroline would binge for 3-4 hours at a time and would then purge all the food she ate, and start the whole process again. Caroline’s body was slowly shutting down, and she was soon hospitalized, but she still found ways to purge without the staff noticing, vomiting in plastic Ziploc bags. She was then recommended to admit herself to an eating disorder clinic. It took several months, but the staff began to notice improvement; a significant decline in self-harm behaviors and purging (she made it two weeks without vomiting her food up). Often, when insurance companies begin to see this progress and that the patient is at a healthy weight, they will remove her from the facility, because it is no longer considered “medically necessary” for Caroline to stay there. However, if clinicians were to say that it is necessary for her to remain in the facility due to her emotional instability and inability to cope without significant help, insurance companies may deem her “treatment refractory” and terminate the rest of her coverage. It is a catch-22 situation–she has to be “sick enough” to receive treatment but also motivated enough to want to recover.

Medical Necessity, Authenticity, BPD in Institutional Care, and Insurance Narratives in Psychiatry

Brokering Authenticity,' the importance of considering BPD in ED Clinics changes the treatment process entirely. Lester’s (2009) analysis of one clinic demonstrates the consequences to an individuals well being when removing that individual from treatment early. One of Lester’s (2009) reasons for these consequences was that BPD symptomology appearing at the eating disorder clinic were never fully resolved and therefore inhibiting a full recovery. Furthermore, Caroline’s story demonstrates the view insurance companies hold towards individuals with BPD: a hopeless case. Miller et al. (2025) research provides more solutions/necessities to ED clinics, including treatment approaches that look at both BPD and ED at the same time. Caroline’s story demonstrates this idea perfectly, by only trying to change her eating behaviors she immediately arrived back at unhealthy coping mechanisms upon release of rehabilitation because her BPD pathology was not integrated into the treatment process. 


Brokering Authenticity,' the importance of considering BPD in ED Clinics.

The goal of Lester's (2010) research is to demonstrate the institutional expectations that clinicians must meet that are not necessarily realistic for patients struggling with BPD. For instance, eating disorder patients with BPD or BPD behaviors will often appear manipulative or inauthentic in their treatment process to the point that insurance companies will cut the resident’s treatment once they reach a healthy weight. This is because, at some point, insurance companies believe that this individual does not want to heal or improve, and so the remaining resources are better utilized elsewhere. 

Providing continued care for ED patients with BPD Comorbidity.

Due to insurance companies pulling out treatment resources when they hear borderline terminology and seeing physical improvement, the residents' clinicians will avoid specific words or frame their BPD patients’ behaviors or progress more vaguely to promote the continued treatment of the patient  (Lester 2009). Unfortunately, pulling a client out of treatment early ultimately results in relapse, and even if the patients get a second chance at being put into a rehabilitation center, the results will remain the same if they cannot receive enough care. The clients will fall back into dysfunctional eating behaviors, suicidal ideation, or their bodies will not be able to keep up with this lifestyle and will shut down. Thus, clinicians have a difficult job, almost competing against the American healthcare system, so that their clients may fully recover.

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