Nancy Potter

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. ..

In lieu of an abstract, here is a brief excerpt of the content:Memory and the Instituting Social ImaginaryNancy Nyquist Potter*, PhD (bio)Emily Walsh's Article on the way that colonialism is perpetuated in psychiatry through dominant collective memory is simultaneously exciting and challenging, and merits active engagement toward making changes (Walsh, 2022). This presents a challenge to clinicians to address entrenched, often subconscious, ways of being with and helping racialized people with historical memories and current experiences.Such changes are necessary in that dominant collective memory is contributory to mental illness, as Walsh writes. It also contributes to what Walsh calls a traumatic loop, whichinvolves feeling unwell due to racist abuse or the effects racialization has on the psyche, then being unable to voice these concerns to the practitioners who desire to help you. Not having the opportunity to voice these concerns can make patients feel as though these memories are not important, thereby invalidating their own negative experiences of racialization.(Walsh, 2022, p. 232)For these reasons, it is crucial that psychiatrists fully understand the harm they can do by reproducing dominant collective memories and work to change this in themselves and in the institutional systems in which they see patients/service users.I focus on one question briefly and then turn to the heart of active engagement.The question concerns what the content of dominant collective memory is and how it might play out in a particular interaction in psychiatry. This is important for clinicians who want to learn what sorts of changes need to be made in order not to continue to enact colonialism and to avoid doing harm. Walsh does a fine job setting out forms of memory and how Fanon (and she) suggest that clinicians can assist patients toward liberation from dominant collective memory. Yet I am left with uncertainty about what sorts of dominant memory serve to deny the violence in the colonized. A bit of filling out on this idea would help the motivated to move toward change.A pressing question is how to facilitate such changes. Both the limitations and the possibilities of the social imaginary can help us understand why change is so difficult and yet how it nevertheless is possible and, in fact, necessary. The social imaginary, as Code explains it, "refers to implicit but effective systems" of values, meanings, interpretations of reality, norms for living, what counts as knowing and who can be knowers, that are found in a social-political order in ways that shape our sense of self, our ways of relating to others, our responsibilities, and a sense of place (Code, 2008, pp. 31–32). The instituted social imaginary, then, tells us what sorts of persons we should be and [End Page 241] how we should see and treat others. It shapes memories and limits which memories—and whose memories—get acknowledged and which ones and whose memories are erased or ignored. It is difficult to see for what it is because it is implicit and assumed to be fixed and natural. However, this is the instituted social imaginary, where the content of the imaginary is taken as given and is naturalized. It trades in stereotypes of Black and Indigenous and other people of color as well as stereotypes of queers, people living with disabilities, the homeless, and others. It is harmful in that it perpetuates those stereotypes, controls patients/ service users, negates their own personal and community identities, and erases episodic memory. It is difficult to change because it is entrenched and often not questioned. Nevertheless, the instituted social imaginary is not totalizing. There is hope, and energy, and excitement to be found in active engagement with an instituting social imaginary. Here, we find people and communities working to critique the given, the naturalized, and even ourselves: "Imaginatively initiated counterpossibilities interrogate the social structure to destabilize its pretensions to naturalness and wholeness, to initiate a new making" (Code, 2008, pp. 34–35). In the final section, I begin to fill out these moves in relation to Walsh's work on memory and psychiatry.Clinicians are trained to be good listeners, and many of them already practice good listening skills in interacting with their patients/service users. However, many patients' experiences...

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...

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.

Sarah Kamens invites readers to consider ways that psychiatry is colonizing, drawing on the concepts of ghostwriting and voice-hearing as mirrored points of haunting in medical regimes. Her article is provocative and engaging, and she is spot on about some of the more concerning aspects of psychiatry. I suggest some ways that Kamens can expand on this work, but my emphasis is on ghostly and emergent voices of service users.I find myself wishing that Kamens would dig deeper into some of the core concepts she employs. Take post-colonialism. Setting aside the fanciful thinking signified by use of the suffix “post”—a term that is used to indicate that we have moved past the practice itself, as in “post-racial society”...

In lieu of an abstract, here is a brief excerpt of the content:Vice, Mental Disorder, and the Role of Underlying Pathological ProcessesNancy Nyquist Potter (bio) and Peter Zachar (bio)Keywordsresponsibility, virtue theory, cultural norms, psychopathologyThe issues discussed by John Sadler are among the most complicated in the philosophy of psychiatry, if for no other reason than that they highlight an area where disciplinary fault lines between clinical psychiatry/ psychology and philosophy seem most evident. We spent a year writing an article on the relationship between the assessment of personality disorders and moral evaluations, and these fault lines became manifest not only between ourselves, but also when discussing our ideas with members of the various disciplines.Many practicing psychiatrists acknowledge that moral attributions (such as manipulativity) might be made about people with certain disorders (such as borderline personality disorder), but also find the argument that psychiatric diagnoses are moral rather than medical conditions to be a ludicrous bit of antipsychiatry in the Szaszian tradition. Philosophers, on the other hand, are less involved with these diagnostic categories in their day-to-day work and are more willing to be skeptical. Whether they are doing philosophy of psychiatry, moral theory, or sociopolitical philosophy, they are interested in digging a little bit deeper and are not impressed by arguments to the effect that—it’s obvious that these are really disorders. Being “obvious” is not a persuasive philosophical argument.The metaphysical task of determining what belongs in the category of criminality compared with other ways of sorting behavior has parallels in moral philosophy: Why is fraud, or theft, criminalized whereas (most) lying is not? Why is one set of moral norms enforceable, whereas a second set is aspirational? Does the difference involve property, where infractions of property are thought to be more serious wrongs than lying, which is “only” psychological rather than material? Are the “most serious” wrongs the ones we mark as crimes? Why is sodomy still criminalized in some areas but betraying one’s lifelong love is viewed as morally reprehensible but not criminal? Both actions are private, and only one seems to do harm—unfaithfulness—yet that is the one that is not criminalized. The point here is that, regardless of domain, our classification systems need to be justifiable, yet justification is most often mystifying. [End Page 27]The same is true for classifying mental disorders. The class of mental disorders appears to be a somewhat inconsistent collection of heterogeneous conditions and does not form a natural kind (Zachar 2000). At the most, the class of mental disorders names a family of loosely related conditions and the reasons for inclusion can shift from disorder to disorder.If the class of mental disorders does not specify an internally coherent kind akin to gold, deciding on the scope of psychiatric practice becomes an important problem. As Sadler asks, for what reasons do we classify pedophilia with schizophrenia—both as disorders—but omit sadism? This is an important question of disciplinary scope.This question of scope is itself ethically charged because, on the one hand, bringing a condition under the purview of psychiatry offers the possibility for treatment, and at least establishes the goal of improving the lives of people with specific kinds of problems. Making lives better is one of the humanistic justifications for science itself; clearly it is a raison d’être of psychiatry. On the other hand, medicalization sets up the conditions for a certain kind of social control. Hospitalization, educational services, day treatment, and disability payments are all contingent upon psychiatric diagnostic practices. These programs and the institutions that manage them are both socially available and socially prescribed. The diagnosed behaviors can now be considered to be entities, and explanations of them can be developed. New technologies for altering them will also be introduced. Such practices have been associated with dehumanization (Phillips 2009).Two important questions also need to be distinguished. The first is a question for moral philosophy—What degree of responsibility do people with putative mental disorders have for their behaviors? For example, should people with psychotic disorders or personality disorders be held responsible for crimes they commit? If so, under what conditions? Should responsibility for certain behavior be mitigated? If so, under what conditions? Moral philosophy...

We are pleased with the thought-provoking discussion that our article has stimulated. All of the discussants agree that the state of education and infusion of ethical principles and practices into psychiatric decision making is currently suboptimal. The ethical questions raised by the discussants, writ large, have been analyzed, reduced to a seemingly manageable 'core,' or expanded to capture nuance and subtlety, and it is invaluable for clinicians, patients, and others to explore them together.In modern times, where the prevailing Western ethical theories were developed, the aim of ethics was to do the right thing. For example, we ought to aim to maximize overall usefulness based on consequences of actions, or to...

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...

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...

Tamara Browne argues that many of the controversies that emerge in the process of revising DSMs could be solved by the creation of an Ethics Review Panel, similar to that of a research ethics committee. Members of such a panel would, in Browne's words, "help inform psychiatric classification". Browne's proposal is important on a number of levels, the most significant one being that it affirms the status of ethics as equal to that of science. An Ethics Review Panel would do more than merely make the processes of scientific and ethical judgments parallel: if Browne's suggestions were followed, it would raise ethical considerations to that of second-order status to scientific judgments in the...

Theories of humor tend to neglect the role that humor plays in situations of conflict. This paper explores epistemological and political dimensions of humor as it is used by members of disenfranchised and otherwise marginalized groups. Not only can this kind of humor I call "oppositional" aid members of oppressed groups in preparing for conflict; it can also help people's beliefs shift in politically significant ways. Although I think the use of oppositional humor can be very constructive both politically and epistemologically indealing with conflict, I am skeptical about the use of oppositional humor in situations of direct conflict resolution. Nevertheless, I suggest that a type of humor called banter can be productively engaged in by the relatively disempowered when certain parameters are drawn.

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.

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 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.

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.

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 work stands at the crossroads of two current themes in moral philosophy: heightened interest in the topic of trust and renewed interest in virtue ethics. In concurrence with the recent renaissance in virtue ethics, I take the central question in morality to be how we are to become morally good persons. An analysis of trust and failures of trust, therefore, should indicate what is involved in becoming worthy of others' trust as well as indicate when trust and distrust are reasonable. I argue that framing these concepts in terms of Aristotelian virtue ethics provides us with an illuminating and constructive way to think about a topic that has, until recently, been largely ignored in philosophical discourse. ;The theoretical framework provides an analysis of the concept of trust, showing how features of trust lead to an understanding of what is involved in being trustworthy. I argue for the centrality of character to moral theory and explain what trustworthiness would look like in an Aristotelian framework. In doing so, I set out central features of what is required to be fully trustworthy. ;I am concerned, in particular, to articulate and defend a theory of the virtue of trustworthiness that takes into account relations of power. My objective in theorizing about trustworthiness has been to provide a conceptual account which generates practical considerations for the enhancement of trusting relationships by attending to the ways in which social and political institutions and practices intersect with the virtue of trustworthiness. To this end, after setting out the theoretical framework, I examine four particular contexts in which power differentials between and among individuals affect trusting relationships. With each case study, different aspects of trustworthiness will be foregrounded; I identify and clarify the particular issues involved and articulate ways in which variously located persons can become trustworthy

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.