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.
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. (shrink)
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... (shrink)
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.". (shrink)
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... (shrink)
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. .. (shrink)
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... (shrink)
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. (shrink)
Fostering shame in societies may not curb violence, because shame is alienating. The person experiencing shame may not care enough about others to curb violent instincts. Furthermore, men may be less shame-prone than are women. Finally, if shame is too prevalent in a society, perpetrators may be reluctant to talk about their actions and motives, if indeed they know their own motives. We may be unable accurately to discover how perpetrators think about their own violence.
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... (shrink)
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”... (shrink)
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 .. (shrink)
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... (shrink)
The construct for affiliation in Depue & Morrone-Strupinsky's (D&M-S's) study is restricted to the interpersonal domain. This restriction is not found in other disciplines. It may be necessary in early stages of trait research. But the construct will need to be expanded to speak to the more complex, second-order affiliations of which humans are capable.
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... (shrink)