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. 

Saint Olaf College

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

Costa, J., Marôco, J., Pinto-Gouveia, J., Ferreira, C., & Castilho, P. (2016). Validation of the Psychometric Properties of the Self-Compassion Scale. Testing the Factorial Validity and Factorial Invariance of the Measure among Borderline Personality Disorder, Anxiety Disorder, Eating Disorder and General Populations. Clinical Psychology and Psychotherapy, 23(5), 460–468. https://doi.org/10.1002/cpp.1974

Bozzatello, P., Garbarini, C., Rocca, P., & Bellino, S. (2021). Borderline Personality Disorder: Risk Factors and Early Detection. Diagnostics (Basel, Switzerland), 11(11), 2142. https://doi.org/10.3390/diagnostics11112142
Khosravi, M. Eating disorders among patients with borderline personality disorder: understanding the prevalence and psychopathology. J Eat Disord 8, 38 (2020). https://doi.org/10.1186/s40337-020-00314-3

Dyson Tori, Thomas Susan J., Townsend Michelle L., Finch Adam, South Alexandra, Barkus Emma, Walter Emma, Mendonca Carley, Grenyer Brin F. S., Pickard Judy A. (2023). Salivary testosterone and cortisol levels in borderline personality disorder before and after a 12-week group dialectical behavior therapy intervention. Frontiers in Psychology, 14(14). https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2023.1195187

Federici, A. (2009). Dialectical Behaviour Therapy for the Treatment of Eating Disorders. NEDIC, NEDIC Eating Disorders Bulletin.

Lee, K. S., & Vaillancourt, T. (2024). Trajectories, comorbidity, and risk factors for adolescent disordered eating and borderline personality disorder features. Development and Psychopathology, 36(4), 1546–1557. doi:10.1017/S0954579423000792

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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

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

Navarro-Haro, M. V., Botella, C., Guillen, V., Moliner, R., Marco, H., Jorquera, M., Baños, R., & Garcia-Palacios, A. (2018). Dialectical Behavior Therapy in the Treatment of Borderline Personality Disorder and Eating Disorders Comorbidity: A Pilot Study in a Naturalistic Setting. Cognitive Therapy and Research, 42(5), 636–649. https://doi.org/10.1007/s10608-018-9906-9

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Ni, X., Chan, D., Chan, K., McMain, S., & Kennedy, J. L. (2009). Serotonin genes and gene–gene interactions in borderline personality disorder in a matched case-control study. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 33(1), 128–133. https://doi.org/10.1016/j.pnpbp.2008.10.022.

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Reference List: Comorbidity of Borderline Personality Disorder and Eating Disorders

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

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

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

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.

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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