Nancy Potter

This article critically examines Louis Charland’s claim that personality disorders are moral rather than medical kinds by exploring the relationship between personality disorders and virtue ethics. We propose that the conceptual resources of virtue theory can inform psychiatry’s thinking about personality disorders, but also that virtue theory as understood by Aristotle cannot be reduced to the narrow domain of ‘the moral’ in the modern sense of the term. Some overlap between the moral domain’s notion of character-based ethics and the medical domain’s notion of character-based disorders is unavoidable. We also apply a modified version of John Sadler’s “moral wrongfulness test” to borderline and narcissistic personality disorders. With respect to both diagnoses, we argue that they involve negative moral evaluations, but may also have indispensable nonmoral features and, therefore, classify legitimate psychiatric disorders.

IN THINKING ABOUT the wonderfully helpful comments by Eric Cassell, Suzanne Jaeger, and Deborah Spitz, I find myself grappling with three central questions: How reliable a guide is world traveling? What kind of knowledge can be obtained by world traveling? and, What are the goals of treatment such that world traveling might be thought to serve a purpose? These questions arise from the insights, criticisms, and cautions the commentators provide, and I will weave together possible answers from ideas drawn from the commentaries.

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 work examines the concept of trust in the light of virtue theory, and takes our responsibility to be trustworthy as central. Rather than thinking of trust as risk-taking, Potter views it as equally a matter of responsibility-taking. Her work illustrates that relations of trust are never independent from considerations of power, and that asking ourselves what we can do to be trustworthy allows us to move beyond adversarial trust relationships and toward a more democratic, just, and peaceful society.

We are thankful for the opportunity to reflect more on the difficult problem of the relationship between moral evaluations and the construct of personality disorders in response to the commentaries by Mike Martin and Louis Charland. We begin by emphasizing to readers that this important problem is complicated by the different perspectives of the various disciplines involved, especially, philosophy, psychiatry, and psychology. Incredulity, anger, and dismay are among the reactions we encountered in discussions of these issues, especially with some mental health professionals. Strong reactions on either side of a disciplinary divide occasionally present barriers to a dispassionate discussion of the topic. ..

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.

In most areas of medicine, the physician's primary task is to diagnose the patient's presenting problem by correctly identifying the underlying pathology causing that problem. Diagnoses are established through a process of correlating the information obtained from an interview with the patient about his history of illness and circumstances, with additional evidence of the underlying disease derived from physical examination findings and/or the results of laboratory investigations and diagnostic imaging. In contemporary health care, various movements that call for a shift in clinical care away from underlying disease pathology toward understanding people and their experience of disease are receiving growing...

: 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 (mis)management of the case exacerbated previous violence done to a biracial female. The importance of resistance to dominant ideology is scrutinized.

Ethics, including medical ethics, has historically paid insufficient attention to epistemic rights and wrongs. This neglect fails to recognize the ways ethics and epistemology are intertwined. In the past fifteen years or so, there has been an interest in epistemic issues in medical practices, relationships with patients, and what is called epistemic injustice. Miranda Fricker identifies a kind of epistemic wrong as an injustice and a harm because it diminishes the speaker's capacity of a knower and treats her as uncredible on the basis of prejudice due to their social identity as a member of a group. Scott Waterman inquires into the status of a rejection of unscientific methodologies...

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...

I discuss pedagogical issues that concern incest survivors. As teachers, we need to understand the ways in which the legacy of incest variously affects survivors' educational experiences and to be aware that the interplay of trust, knowledge, and power may be particularly complex for survivors. I emphasize the responsibility teachers have to create classrooms that are inclusive of survivors, while raising concerns about the practice of personal disclosure and assumptions about trust and safety in the classroom.

Furman and Tuminello raise a central question about people living with mental illness: What kind of life is possible for them? Can one live a flourishing life even when struggling with a mental disorder? The authors draw on research studies to argue that a technique called Applied Behavioral Analysis can improve the lives of children with autism. One study, from 1987, found that 47% of children exposed to ABA attained normal IQ levels, adaptive skills, and social skills, and other studies replicated these results. This is a promising avenue for those living with autism.Furman and Tuminello focus on autism, but their claims, if true, might be extended to other disorders as well; as they note, people...

I think that Hanna Pickard and I are in agreement that the dichotomy between ‘having’ and ‘not having’ control and conscious knowledge should be rejected. Personality disordered (PD) service users, like the rest of us, have degrees of not knowing and knowing, controlling and not controlling, such that pinpointing exactly when assignment of responsibility should enter into judgments of service users is murky and difficult. This position includes both metaphysical and epistemological issues in that it is a separate question whether or not we can know someone is responsible from the question of whether or not someone is responsible and to what degree. Because Pickard focuses on metaphysical questions, I raise some ..

This paper raises questions about who counts as a knower with regard to his or her own memories, what gets counted as a genuine memory, and who will affirm those memories within an epistemic community. I argue for a democratic epistemology informed by an understanding of relations of power. I investigate implications of the claim that knowledge is both social and political and suggest ways it is related to trust. Given the tendency of epistemology to draw lines that discriminate unfairly against some, it is vital that efforts to create democratic epistemologies be sensitive to the potential for exploitation. Standards of credibility often favor members of dominant groups, and our ontological commitments may intersect with patterns of domination. While acknowledging difficulties in evaluating what counts as credible claims to memories, I argue that one’s engagement with clients must be mapped onto the larger moral and political domain.

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

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."

This case consultation offers three cases that illustrate a collaborative consultation model for psychiatric ethics that we have developed in outpatient clinic and in emergency psychiatry over the last 10 years. After we present these cases, we discuss three points of interest: 1) the characteristics we found to be important to our collaborative project, 2) the benefits of an integrative approach, and 3) ways that our collaborative moral reasoning developed our awareness of and sensitivity to ethical issues. We end by raising some topics on which commentators could engage.Potter began working with El-Mallakh more than 10 years ago. Her impetus was that she was writing a critique of the criteria used in borderline...