Nancy Potter

People diagnosed with Borderline Personality Disorder (BPD) may engage in what are called self-injurious acts. This paper situates self-injury within a larger cultural context in which body modifications are differently evaluated according to inscribed meanings. To provide a framework for ethical interactions with people diagnosed as BPD who self-injure, I draw on two concepts from theories of meaning: signification and uptake. I suggest possible significations of self-injury, but argue that clinicians have a duty to give uptake to the patient's own interpretations of her behavior. Proper giving of uptake, which involves responding to others' communications such that the communicator's integrity is preserved, is crucial to ethical practices for clinicians, and uptake is never simply neutral or objective. This analysis suggests that sense-making about a client's self-injurious acts involves an understanding not only of the client's own interpretation of her behavior and its meaning, but also of the discursive production and function of such signs in our culture. I offer five maxims to guide the therapeutic process for clinicians working with self-injurious behavior in BPD patients.

This essay examines the relationship between nonviolence and trustworthiness. I focus on questions of accountability for people in midlevel positions of power, where multiple loyalties and responsibilities create conflicts and where policies can push people into actions that reinstate hegemonic relations. A case study from crisis counseling is presented in which the management of the case exacerbated previous violence done to a biracial female. The importance of resistance to dominant ideology is scrutinized.

This chapter sets out several views of empathy that draw not only on psychology's literature but on philosophical and psychiatric writings. Empathy is a set of complex concepts involving perception, emotion, attitudinal orientation, and other cognitive processes as well as an activity that expresses character traits and, hence, one of the virtues. In other words, an examination of the philosophical and clinical literature reveals empathy to be not one unified concept but instead a set of related characteristics and qualities needed to be an ethical and therapeutically effective clinician. To this end, the chapter offers reasons as to why empathy is important to clinical work: empathy is both epistemically and ethically necessary to good social relations and, in particular, clinical relations. It then distinguishes empathy from a related concept called "world"-traveling and situates its relevance to therapeutic relations. Finally it brings these ideas together by highlighting Iris Murdoch's ideas of "just vision" and "loving attention."

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.1 (2003) 33-35 [Access article in PDF] In the Spirit of Giving Uptake Nancy Nyquist Potter IT IS BOTH WONDERFUL and daunting to now be in the middle of a dialogical exchange on the messy and difficult topic of self-injury and how ethically to interact with patients who self-injure. It is wonderful that authors such as Carolyn Sargent have contributed very helpful examples from the discipline of anthropology that expand the ideas I have been grappling with. And it is daunting to begin to sharpen and correct my thoughts along the lines that the commentators suggest. In the spirit of giving uptake both to the praise and the criticism I have received, I first situate the "Commodity/Body/Sign" article in the context of my larger project and then focus on one problem area: my claim that giving uptake is necessary to ethical healing practices. Giving Too Much Uptake to the Dsm Rob Woolfolk is right that borderline is diagnostically imprecise. But what initially caught my interest in this personality disorder was its pejorative connotations. I will mention my favorite example, which comes from a past chairman of the psychiatry department at New York University that "borderliners are the patients you think of as PIAs—pains in the ass," (Medical World News 1983). Why are the patients who exhibit the behaviors associated with borderline personality disorder (BPD) so disliked, I wondered? Who are these patients, and what are they doing that brings upon themselves such rejection? My investigation, in other words, has been focused on behaviors and their meanings, using a philosophical lens to examine underlying assumptions. I completely agree with Woolfolk and Carolyn Sargent that much more analysis needs to be done on BPD, and I am eager to do it. It is true that I do not take up larger questions about the gendered nature of this diagnosis in general (Sargent, Woolfolk), nor do I challenge the validity of the diagnosis in this article (Woolfolk). In my view, that larger project must be held in abeyance until more philosophical probing on a number of other issues is done. Hopefully, my book-length project will benefit from continuing guidance from these authors.I focus first on self-injury for two reasons. First, it is the most common symptom for which people with BPD come to clinical attention (Gunderson 2001, 22). Second, of all the behaviors associated with BPD, self-injurious behavior is the kind that people most tend to dig in their heels about when its status as pathological is questioned. Gunderson cautions that "because the diagnosis of BPD underscores a serious, long-standing mental health problem, the diagnosis should not be offered too readily to anyone who cuts or otherwise self-mutilates" (2001, 23). I add to that caution that we ought not too readily assume that self-injury is pathological: Lynne Cox (2003) swam to the Antarctic Peninsula in water temperatures of 32° Fahrenheit and with 25 foot waves; she suffered nerve damage and numbness in her extremities. Self-injurious behavior? [End Page 33] Pathological? Cox trained for two years to accomplish this feat. In problematizing self-injury, I raise questions about some associations and assumptions we make. Calling into question the whole taxonomy requires looking at symptoms, behaviors, and criteria as a whole, and that cannot be done until systematic analysis of concepts such as self-injury, impulsivity, identity disturbance, and manipulativity are undertaken. To put things in terms of Woolfolk's reasonable criticism that he wishes I would "give less uptake to the framers of the DSM-IV," I appreciate that point. But I do think that those of us who are not ourselves clinicians must do our research carefully and proceed conservatively rather than attempting to tear a house down that may not need to be condemned. Methods and Morals Woolfolk says that the concept of uptake is "familiar and central" to therapy; Katherine Morris says it is "simple and uncontroversial"; Sargent says it is "unexceptionable"; and Christa Krüger says it may be "very difficult if not more or less doomed...

This paper explores the relationship between the bonds of practitioner/patient trust and the notion of a justified lie. The intersection of moral theories on lying which prioritize right action with institutional discretionary power allows practitioners to dismiss, or at least not take seriously enough, the harm done when a patient's trust is betrayed. Even when a lie can be shown to be justified, the trustworthiness of the practitioner may be called into question in ways that neither theories of right action nor contemporary discourse in health care attends to adequately. I set out features of full trustworthiness along Aristotelian lines