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THE CONCEPT OF MENTAL DISORDER: A PRAGMATIC PROPOSAL
By

Dominic A. Sisti

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
DOCTOR OF PHILOSOPHY
Philosophy

2010

ABSTRACT
THE CONCEPT OF MENTAL DISORDER: A PRAGMATIC PROPOSAL
By

Dominic A. Sisti

Although seemingly straightforward, the concepts of health, disease, and illness
are riddled with conceptual ambiguities, which have far-reaching ethical and practical
implications. In recent years, philosophical analysis Of the concepts of health, disease,
and illness has focused largely on the identification of metaphysical markers that
distinguish these concepts and make them recognizable as deviations appearing against a
backdrop of normalcy. The distinction between naturalism and normativism is
operational across what I call the ‘standard theories’ of health, disease and illness. This
distinction turns on an assessment of the role of social values in defining health, disease
and illness. Although I am sympathetic to naturalistic theories, I argue that they suffer
from a number of limitations, which can be seen most clearly in the way they explain
mental illnesses, and, specifically, personality disorders.

Personality disorders are particularly problematic because they are constellations
of behaviors that seem to straddle the domains of mental illness and individual
idiosyncrasy. In thinking about the ways to understand boundary cases of mental illness
such as personality disorders, I argue that naturalistic theories are the best available to us,
but fail because they depend on a concept of biological function and personality disorders
are ultimately social dysfimctions. It is from this distinction that I begin my pragmatic
line of argumentation by claiming that whether a particular state (social dysfunction) is

properly called a ‘disease’ or ‘disorder’ is not a necessary condition of its being treated as

if it were one. In so doing, I augment naturalistic theories with reasonable pragmatic
considerations, such that boundary cases might be justifiably treated as medical problems
despite controversies regarding their biological basis.

In building this pragmatic theory, I focus on the case of borderline personality
disorder. The theory I Offer seeks to move beyond the metaphysical concerns that have
captivated the standard theoreticians by focusing philosophical attention on the actual
suffering of people affected by this personality disorder. As a form of pragmatic
naturalism, my proposal rejects both metaphysical and epistemic foundationalism in
favor of the empirical realities of personality disorders. Thus, as a dimension to this
analysis, I will also suggest that personality disorders be understood in terms of the
public health model, touching on ways to understand and mitigate the far-reaching effects
of mental disorder on others in the community.

Any pragmatic model of mental disorder has a number of vulnerabilities. Most
apparent is the fact that such a model will be open to abuse by those who wish to classify
inconvenient, offensive, or immoral behaviors as mental illnesses. To answer these
objections, I again employ the case of borderline personality disorder to offer an analysis
motivated by social, political, and feminist philosophy to refine my theory. This analysis
is crucial to developing an ethical pragmatic theory that enables an appraisal of what
should count as a mental disorder—an appraisal that hopefully avoids the taint of
political ideologies cleverly disguised in medical terms. I conclude with a brief
discussion of potential policy ramifications presented by this pragmatic theoretical

proposal.

Copyright by
DOMINlC A. SISTI
2010

For Corinne

ACKNOWLEDGEMENTS

This dissertation is the product, not of isolated research and reflection, but Of
several years of conversation with mentors, colleagues, friends and family.

I must first express my Sincere and deep gratitude to my director and mentor, Tom
Tomlinson, Director of the MSU Center for Ethics. Tom was incredibly supportive,
generous, and kind—time and again he set aside his own work to attend to questions
about mine. Tom provided incisive commentary on chapter drafts, challenging me to
consider and reconsider everything you are about to read. I also Sincerely thank my
committee members—Len Fleck, Fred Gifford, and James Nelson—for their feedback
and support throughout the comprehensive exam and dissertation processes and during
my entire time at Michigan State. I am deeply grateful to my many friends, colleagues,
and teachers, all of whom helped make my time at MSU incredibly productive. I thank
Marilyn Frye, Hilde Lindemann, Fred Rauscher, Matthew McKeon, Debra Nails, Lisa
Engelstein, Jennifer Swindell, Chet McLeskey, Jason Mask, Joseph Stramondo, Tricha
Shivas, Alexandra Valadas, and Julie Aultrnan.

Over the past decade, friends from the University of Pennsylvania Center for
Bioethics have had a profound impact on my thinking, research interests, and have
provided me constant support. I am indebted to Arthur Caplan, who has been a wonderful
mentor and friend. Art served as an external reader of this dissertation. I also thank
Jonathan Moreno and Jason Schwartz for their feedback on sections of this project. I
thank past and present faculty and staff of the Center: David Magnus, Paul Root Wolpe,
Erin Wieand, John Kwon, Charles Bosk, David Doukas, Pamela Sankar, Jon Merz, Hila

Rimon—Greenspan all of whom, whether they know it or not, have helped me to grow

vi

both professionally and personally. I am grateful to James McCartney, a Penn Center
Fellow and professor of philosophy at Villanova University, for years of support and
friendship.

During the spring semester of 2008, I was fortunate to be able to Spend several
weeks at the Center for Clinical Bioethics at Georgetown University, where I
accomplished quite a bit of preliminary research for this project. While there, I received
invaluable guidance and feedback from Edmund Pellegrino, Carol Taylor, Jim Giordano,
and Niel Rosen.

I thank George Agich who sent me several helpful reprints and Christopher
Boorse who provided me with clarifications on the complexities of his theory of disease.
I wish to thank Nancy Potter whose critical philosophical work on borderline personality
disorder has been as instructive as it has been captivating. Her recent book, Mapping the
Edges and the In—between: A Critical Analysis of Borderline Personality Disorder (2009,
Oxford University Press), is a rich trove of scholarship and deep personal insight.

Parts of this dissertation’s introduction and first chapter were adapted from my
entry, “Health & Disease: Conceptual Perspectives & Ethical Implications” published in
The Penn Guide to Bioethics, edited by Vardit Ravitsky, Autumn F iester, and Arthur
Caplan (2009, New York: Springer Publishing). Parts Of chapters 6 and 7 were richly
informed by a seminar in feminist bioethics taught by Hilde Lindemann. Other aspects Of
this dissertation were informed by Lisa Schwartzman’s seminar on feminist critiques Of
classical liberalism, Marilyn F rye’s proseminar on the philosophy of language, and an
independent study I completed on the philosophy of medicine of Kant and his

contemporaries under the direction of Fred Rauscher.

vii

Thanks also go to Matthew CerratO for challenging me to consider a feminist
critique of borderline personality disorder and to Rima Saad, staff psychologist at
McLean HOSpital, for her early feedback on this project and for her many years of
friendship. I thank Jed Magen and Christopher Guiliano of the MSU Department Of
Psychiatry for allowing me to Shadow them and for helping to clear up points Of
confusion. I am grateful to anonymous sources who shared their experiences with
borderline personality disorder. I thank Ronda Levine for her help with copyediting this
document. She ably provided her critical eye, found typos and helped reformat my notes
and bibliography.

Finally, my parents, Dominic and Lucille, and my Sister, Elena, all deserve credit
and thanks for their patience, love and support—~both emotional and financial. I thank
Eileen Munro, my 4th grade teacher and close friend. Eileen allowed me to work
independently on the peculiar topics that preoccupied me in 1984. Thanks to Christian
Buckley for his feedback on my introduction and to Jeffrey Nicholas for reliably
providing counterarguments.

Most especially, I thank my wife, Corinne, for tolerating my tendency to question
everything that seems obvious, for her advice and love, and for always keeping me on my

toes with her quick wit and sense Of humor.

~——Dominic A . Sisti, East Lansing, Michigan

viii

TABLE OF CONTENTS

LIST OF TABLES ........................................................................................................ X1
INTRODUCTION: TOWARD A PRAGMATIC THEORY OF MENTAL DISORDER ................ 1
CHAPTER 1: THE CONCEPTUAL LANDSCAPE OF MENTAL HEALTH, DISEASE,

& ILLNESS ......................................................................................................... 10
Introduction ................................................................................................. 10
Naturalism ................................................................................................... l I
Strong Normativism .................................................................................... 14
Moderate Normativism & Hybrid Theories of Disorder ............................ 21
The Social Construction of Mental Illness & Anti-Psychiatry ................... 27
Conclusion .................................................................................................. 32

CHAPTER 2: THE CONCEPTS OF BIOLOGICAL AND SOCIAL (DYS)FUNCTION ............ 37
Introduction ................................................................................................. 37
Pluralism and Function Concepts ............................................................... 38
Biological Function ..................................................................................... 40
Dysfunction & Mental Illness ..................................................................... 52
Biological versus Social Dysfunction: Schizophrenia & the Disordered

Personality ............................................................................................. 58
Conclusion .................................................................................................. 63

CHAPTER 3: THE PRAGMATICS OF MENTAL DISORDER: A THEORETICAL

SYNTHESIS ......................................................................................................... 67
Introduction ................................................................................................. 67
Agich’s Pragmatic Theory of Mental Illness .............................................. 72
Banja’s Pragmatic Theory ........................................................................... 83
Identifying Theoretical Gaps ...................................................................... 86

CHAPTER 4: A PRAGMATIC THEORY OF MENTAL DISORDER ................................... 90
Introduction ................................................................................................. 9O
Vignettes ..................................................................................................... 95
Suffering and the Ends Of Medicine ........................................................... 98
Habit .......................................................................................................... 105
Beyond “Mad or Bad?” ........................................................................... ‘.. I ll
Hypersexuality and the Consequences of Exculpation ............................. 121
Public Health and Personality Disorders .................................................. 126
Conclusion ................................................................................................ I30

ix

CHAPTER 5: PRAGMATIC ASCRIPTIONS OF MENTAL DISORDER: ETHICAL

SUBTHEORIES ................................................................................................... 134
Introduction: Anticipating Objections ...................................................... 134
Virtues of Individual Practitioners ............................................................ I38
Macroethical Considerations .................................................................... 155
Conclusion ................................................................................................ 168

CHAPTER 6: AN ETHICAL-PRAGMATIC RECONSTRUCTION OF BORDERLINE

PERSONALITY DISORDER (PART I) ................................................................... 170
Introduction ............................................................................................... 170
Basics ........................................................................................................ 173
An Historical Sketch ................................................................................. I75
Tropes & Caricatures of the Borderline Woman ...................................... 182
The Liberal Self ........................................................................................ 186
Biological Function & Borderline ............................................................ I95
Stigma ....................................................................................................... 198
Conclusion ................................................................................................ 200

CHAPTER 7: AN ETHICAL-PRAGMATIC RECONSTRUCTION OF BORDERLINE

PERSONALITY DISORDER (PART II) .................................................................. 204
Introduction ............................................................................................... 204
Reconsidering Classification .................................................................... 206
Recasting Symptoms: Manipulation & Impulsivity ................................. 211
Rethinking Treatment: Dialectical Therapy & Uptake ............................. 216
Recognizing Public Health Risks: Systems Therapies ............................. 219
Conclusion ................................................................................................ 224

CHAPTER 8: PRAGMATIC ASCRIPTIONS OF MENTAL DISORDER: POLICY

CONSIDERATIONS ............................................................................................ 226
Introduction ............................................................................................... 226
Political Recognition, Participation, and Shifiing Categories .................. 227
Reasonable Accommodation: ‘Mad’ versus ‘Bad’ Redux ........................ 234
Expanding Access ..................................................................................... 238
Future Research ........................................................................................ 241

BIBILOGRAPHY .................................................................................................... 244

LIST OF TABLES

TABLE I: SELECTED ITEMS DESCRIBING PATIENTS WITH BORDERLINE
DISORDER OR DYSTHYMIA (INCLUDING BPD PATIENTS) FROM THE

SWAP-200 ASSESSMENT PROCEDURE, CROSS-REFERENCED TO
POTENTIAL GENDER BIASES THAT ARE RELATED TO THE LIBERAL IDEAL

OF THE SELF ..................................................................................................... 194

xi

INTRODUCTION: TOWARD A PRAGMATIC THEORY OF MENTAL DISORDER

Although seemingly straightforward, the concepts of health, disease, and illness
are riddled with conceptual ambiguities, which have far-reaching ethical and practical
implications. Notwithstanding the ease with which physicians talk about the symptoms
and cures of a particular disease or encourage patients to live a ‘healthy’ lifestyle, a

moment’s reflection reveals these interrelated concepts are both philosophically complex
and exceptionally imprecise. If asked, most people would find it difficult to settle on a
determinative statement about what counts as a disease and what it means to be healthy.
Most would probably agree that breast cancer and HIV/AIDS are undoubtedly diseases.
Others might raise their eyebrows when asked about attention-deficit hyperactivity
disorder (ADHD) or restless leg syndrome.

Why the ambivalence? Are the concepts of health, disease, and disorder so
amorphous that they are completely subjective? Is it possible to determine biological
standards and an Objective method for determining what constitutes health and disease?
Should the concept of disease be limited to merely biological abnormalities? And, if so,
who decides what is normal or abnormal? These questions suggest that the concepts of
health and disease are moving targets—as they pass in and out Of our conceptual sights,
they become impossible to pin down.

As impossible as conceptual clarity may seem, for both biomedical ethics and
medicine, the meanings of basic concepts so often employed must be constantly
reexamined and clarified. This is true in any mature discipline. Legal theorists, for
example, continue to debate basic concepts of jurisprudence and political philosophy. But

just as there are sometimes profound consequences when philosophical concepts are

brought to bear in constitutional law, there are similarly far—reaching effects when the
concepts of health and disease are critically examined or when they are haphazardly
overlooked for the sake of expedience. Thus, in order to craft sound bioethical
arguments, theories, and public policies it is first crucial that we clarify the most
fundamental concepts of medicine.
As Edmund Pellegrino has suggested, “clarification of medicine’s basic concepts

is as much a moral as an intellectual obligation. . .confusion about the nature of health and

disease is ultimately confusion about the concept of medicine itself.”1 I therefore present
this dissertation as a contribution to the larger philosophical effort that seeks to clarify the
concepts of health, disease, and illness with an eye toward practical solutions of problems
in biomedical ethics and mental health policy.

In recent years, philosophical analysis of the concepts of health, disease, and
illness has focused largely on the identification of metaphysical markers that distinguish
these concepts and make them recognizable as deviations appearing against a backdrop of
normalcy. As we will see, there is a basic distinction that is operational across what I
call the ‘Standard theories’ of health, disease and illness. This distinction, albeit packaged
in various and diverse ways, turns on an assessment of the role of social values versus
biological facts when defining health, disease and illness. As I will detail in the first
chapter, there are two very broad categories Of standard theories. According to standard
naturalistic theories, the ontological reality of disease is explained in terms of biological

function, and while values might play a role in defining disorders or illnesses,they are
not determinative of disease. I will explain how normative features when applied to

diseases may result in the ascription of ‘illness.’ Christopher Boorse has most notably

advanced this model.2 In contrast, standard normative theories give social values a central
and determinative place in nosology. For example, a normative model that focuses on the

contextual features of function and dysfunction vis-a-vis the concepts health and disease

has been articulated most clearly by H. Tristram Engelhardt.3 To unpack these models, I
will analyze the notions of biological function and dysfunction that serve as the
foundation for theories that aspire to describe diseases as natural kinds. I hope to Show
how these models are generally superior to more normative or social models of disease
when describing core cases of disease—things like cancer, infectious disease, and
schizophrenia.

However, I will also acknowledge the problems of naturalistic theories, focusing
on the ways in which the contemporary philosophers of medicine have conceptualized
mental illness by surveying the landscape of theoretical models of mental illness.
Notwithstanding vehement Objections by antipsychiatry enthusiasts, I will argue that core
cases of mental illness can be described according to the key markers proposed by
naturalists. AS an extension of a naturalistic theory, Jerome Wakefield’s hybrid theory,
which combines the notions of biological function and social values, is especially usefirl
for describing core cases Of mental illness. I will present the paradigm cases of

schizophrenia and severe depression to illustrate the advantages of a hybrid theory such
as Wakefield’s.
As we will see, standard and hybrid theories suffer from a number of serious
limitations, which can be seen most clearly in the way they handle personality disorders.
Personality disorders are particularly problematic because they are constellations of

behaviors that seem to straddle the domains of mental illness and individual idiosyncrasy.

the expectations of a particular society or culture.4

I therefore will consider several preliminary questions: Should these behaviors be
considered symptomatic of a mental illness or Should they be considered instances of
individual vice or moral failing? How might we distinguish their unique features to
justify including them in our psychiatric nosology? What are some of the risks of firrther
medicalizing such boundary cases of mental illness? To explore these and other
questions, I will Offer a multifaceted philosophical analysis of personality disorders that
includes their sociological and political dimensions. 1 will eventually focus this critical
analysis on borderline personality disorder.

In thinking about the ways to deal with boundary cases of mental illness such as
personality disorders it seems there are four basic options. ( I) We can decide to commit
to one of the standard models and question the legitimacy of boundary cases as perhaps
better described as ‘problems of life’ or behavioral idiosyncrasies that fall outside the
purview of medicine. This is the option offered, for example, by anti-psychiatry
advocates such as Thomas Szasz. (2) Alternatively, we can maintain a more Optimistic
naturalistic perspective, and envision a day when scientific research provides Clear
evidence of a biological dysfunction upon which to base our diagnosis of personality

disorders. Wakefield seems to espouse such a Speculative approach. (3) We might

 

 

question the conceptual basis of the naturalistic models and jettison those theories
wholesale. Instead, we might ambitiously pursue an entirely new theory Of mental illness
that will more accurately capture our intuitions about boundary cases. Social
constructionists, many of whom insist the concepts of health and disease are ultimately
social contrivances, take this tack. (4) Or, finally, we might accept naturalistic theories as
the best available to us, but then argue that whether a particular state is prOperly called a
‘disease’ is not a necessary condition of its being treated as if it were one. To do this we
might augment naturalistic theories with reasonable pragmatic considerations, such that
boundary cases might be justifiably treated as medical problems despite controversies
regarding their biological basis. The ultimate goal of this dissertation is to pursue the
fourth option.

Before I offer my own theory in chapters 4 and 5, it will be first important to
explain why pursuing the other options is neither philosophically nor practically
desirable. In short, the first and second options seem to dismiss without proper
justification the causes of suffering that Slip through the theoretical lacunae of the
standard models. In chapter 2, I will describe the key shortcomings that limit the
applicability of the standard models to instances of mental illness and the problematic
consequences of these limitations. I will look carefully at Boorse’s theory and
Wakefield’s hybrid model of mental illness and show why their theories, by design, fail
to adequately explain the reality of personality disorders. From the other pole of the
debate, I will describe the positions of social constructionists and anti-psychiatry
theorists, who insist the notion that mental disorder is anything but a socially determined

contrivance.

The third Option presents us with the opportunity to develop an entirely new
theoretical framework for the concepts of mental health, disease, and illness. Because this
strategy is based largely on a social model of health and disease, which eschews the
Objective nature of core cases of disease and disability, it leads to counterintuitive
conclusions. This option also seems impractical, particularly because it ignores the
Significant work and progress made by theoreticians who have described the reality of
core cases of disease and illness, simply because their work has not been perfect in
addressing boundary cases. But building a new theoretical framework from the starting
point of boundary cases is not prudent. Just as hard cases make bad law, boundary cases
of illness would make bad nosological theories and would sacrifice what I believe could
be an adequate theory in search of a perfect one.

Therefore, we are left with what I argue is the most parsimonious and promising
option—developing a pragmatic model of boundary cases of mental illness that augments
and complements the standard naturalistic models. Although I will draw upon the work of
philosophy and psychology of Pragmatists William James and John Dewey, my proposal
should be characterized as pragmatic in the colloquial sense. The basic goal of this theory
is rather straightforward: identifying constellations of behaviors that cause suffering and
trying to figure out how to minimize that suffering. In one sense, the pragmatic theory I
will offer might be characterized, like Wakefield’s, as a hybrid theory because it starts
from a set of naturalistic premises about the nature of disease and builds out from there.
However, it is not genuinely naturalistic because the pragmatic adjunct to this theory is
wholly determined by particular social values. As I will detail, I have no expectation that

biological markers or correlates will ever be discovered, nor need be discovered, for

personality disorders and other boundary cases to be correctly considered legitimate
mental illnesses. Social dysfimction is enough, according to this approach, to establish a
constellation of behaviors as a mental illness. I will preview my own theory by
synthesizing two other pragmatic theories in chapter 3.

The pragmatic model I will offer seeks to move beyond the metaphysical
concerns that have captivated the standard theoreticians by focusing philosophical
attention on the actual suffering of people affected by personality disorders. Thus, as a
form of pragmatic naturalism, my proposal rejects both metaphysical and epistemic

foundationalism in favor of the empirical realities as people in the world experience

them.5 Thus, I will offer a phenomenology of personality disorders to support one Of the
key facets of my overall argument: that personality disorders Should count as mental
illnesses particularly because of the actual, palpable suffering they cause patients, family
members, and the larger community. Of course, many things cause suffering and are not
considered illnesses. So I will explain why I think the specific kind of suffering
experienced by people affected by personality disorders falls within the scope of medical
expertise and is deserving of medical attention. As a dimension to this analysis, I will
also suggest that personality disorders be understood in terms of the public health model,
touching on ways to understand and mitigate the far-reaching effects Of mental disorder
on the community.

Any pragmatic model of mental disorder has a number of significant
vulnerabilities. Most apparent is the fact that such'a model will be open to abuse by those
who wish to classify what they consider to be inconvenient, offensive, or immoral

behaviors as mental illnesses. Therefore, in chapters 5 through 7, I will offer a critical

analysis motivated by scholarship in social, political, and feminist philosophy to help
refine my theory. This analysis will prove crucial to developing an ethical pragmatic
theory that enables an appraisal of what should count as a mental disorder—an appraisal
that hopefully avoids the taint of political ideologies cleverly disguised in medical terms.
Again, as a case study, I will turn to the borderline personality disorder. Uncovering the
social and political biases that historically motivated the diagnostic criteria for borderline
allows us to more carefully parse the expectations and values implicit in the current DSM
framing of personality disorders. Similarly, the cycle of medicalization and
demedicalization of homosexuality will serve as an example of how certain behaviors,
which merely deviate from mainstream or traditional mores, have been unjustifiably
classified as diseases.

AS I discuss these examples, it will be important to note that although, in some
cases, the reification of behaviors as ‘disorders’ might have been caused by ulterior
political motives, this does not necessarily mean that categorization of those behaviors is
unnecessary or inappropriate today. On the contrary, an understanding of the intentions of
the agents of medicalization (e. g. pharmaceutical companies, professional institutions
such as the APA, advocacy groups such as the National Alliance on Mental Illness) is
only one part of the larger analysis. I hope to Show that in the case of borderline
personality disorder, gender bias had largely motivated the definition and expansion of
what I describe as the standard construction of the diagnostic category.

Today, however, we are hopefully equipped with a more sophisticated
understanding of borderline personality disorder that recognizes its problematic history

yet acknowledges it as a serious psychological problem. The therapeutic goal of

medicine—rooted in the authentically beneficent desire to relieve the suffering Of
patients—can and should now supersede these more base political intentions and further
motivate research and enhanced access to therapy for personality disorders such as
borderline. Thus, the historical account provides us with an anti-paradigm, which Offers
a cautionary note about the moral hazards of expanding a psychological category based
on merely pragmatic, albeit unethical, considerations.

Finally, in developing a pragmatic theory of mental disorder, I hope this
dissertation will offer a compelling set of arguments for use by patients and families who
are affected by personality disorders and who seek recognition and help. Though it
should be expected that any pragmatic theory would necessarily aim for real social
change, I should state openly that my motivation for writing this dissertation is both
philosophical and political. By marshalling the strongest philosophical arguments about
the troubling reality of mental illness and particularly of boundary cases, I hope to
advance the cause of those who seek mental health care parity in a deeply polarized and
largely unsympathetic political environment. Ways to actualize these political aspirations

will be suggested in chapter 8.

 

l. Edmund D. Pellegrino, "Foreword: Renewing Medicine's Basic Concepts," in Health, Disease,
and Illness: Concepts in Medicine, ed. Arthur L. Caplan, James J. McCartney, and Dominic A. Sisti
(Washington DC: Georgetown University Press, 2004), xii.

2. Christopher Boorse, "On the Distinction Between Disease and Illness," in The Concepts of
Health and Disease, ed. Arthur L. Caplan, H. Tristram Engelhardt, Jr., and James J. McCartney (Reading,
MA: Addison-Wesley, 1981), 545-560.

3. H. Tristram Engelhardt, Jr., The Foundations of Bioethics, 2nd ed. (New York: Oxford
University Press, 1996). ' ‘

4. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th
ed., text rev. (Washington, DC: American Psychiatric Association, 2000).

5. Jonathan Moreno, “Bioethics is a Naturalism,” in Pragmatic Bioethics, 2nd ed., ed. Glenn

McGee (Cambridge, MA: MIT Press, 2003)

CHAPTER 1

THE CONCEPTUAL LANDSCAPE OF THE CONCEPTS OF MENTAL
HEALTH, DISEASE, & ILLNESS

Introduction

Over the past several decades, the list of terms used to describe theories of health,
disease and illness has become quite expansive.l Various scholars have defined these
concepts in terms of fundamental metaphysical commitments (e. g. essentialist vs.
nominalist), the influence of social values (e.g. the medical vs. social models of
disability), and the locus and cause of the disease in question (e. g. xenochtonous vs.
autochtonous). Several theories of health and disease delineate between epistemic (e.g.

deduktiv vs. empiristisch) and linguistic variations (e. g. natural kind semantics vs.

descriptive semantics) of the concepts.2 This wide array of terms used to denote the
concepts of health, disease, and illness has led some to suggest that the debate about the
ontology of these concepts is now confused and will remain irresolvable without serious
clarification of theoretical assumptions.3

In this dissertation, I will distinguish between the various explanations of the
concepts of health, disease, and illness by using two very broad categories, which reflect
the lines of debate about the ontology of disease and illness as being roughly drawn
between naturalistic theories or normative theories. Simply put, nosological naturalists
contend that disease can be understood according to objective biological markers and that
diseases are caused by real entities or phenomena. Diseases and derivative illnesses are
biologically based. Generally, naturalists consider diseases to be natural kinds. Much

like the planets or chemical elements, naturalists contend diseases exist in nature and are

10

independent of human experience, interpretation, or contrivance. In contrast,
normativists argue that social values play a critical role in any theory of health, disease,
and illness and they eschew scientific positivism. In particular, strong normativists argue
that it is impossible to disentangle social norms and values fi'om even the most basic
concept of disease. A third kind of theoretical approach seeks to hybridize the naturalist

intuitions about the biological reality of health, disease, and illness while simultaneously

recognizing the role values play particularly in defining ‘illness’ and ‘disorder’.4 I will
be discussing the distinction drawn by these theoreticians between the concepts of disease
and illness.

I am choosing to delineate between naturalism and normativism because they
provide the broadest swath of theoretical landscape against which to later frame a
pragmatic theory of mental illness. In this chapter, I will first present a survey of
naturalism and normativism alongside influential hybrid theories. I will then focus on
specific critiques of naturalism in mental illness by describing insights from social
constructionists such as Michel Foucault and Thomas Szasz. The goal of this chapter is
to provide the reader with a basic background on theories of health, disease and illness in
preparation for detailing the specific problem of how, where, and why personality
disorders might fit into a pragmatic theory of mental illness. Let us begin with

nosological naturalism.

Naturalism
Naturalism locates its historical roots in the ancient theories of Hippocrates &

Galen, who considered diseases to be necessarily constituted by imbalances in the four

11

humors: black and yellow bile, phlegm, and blood. The humoral theory of disease
persisted for centuries through the Middle Ages, when Paracelsus described the cause of
disease as imbalances in the body’s three essential substances (salt, mercury, and sulfur),
which resulted from autonomous entities “springing from the body.” Centuries later, the
modern concepts of health and disease, as with the practice of scientific medicine itself,
became dependent on Cartesian mechanistic reductionism and mind/body dualism. SO-
called ontologists such as Fracastorius (1546), Thomas Sydenham (1670) and 19th
century polymath, Rudolf Virchow, located the cause of disease and epidemic not in
internal imbalances but rather discrete causal agents (spores, miasma or ens morbi) that
entered the body.5

Contemporary naturalists have moved well beyond the theories of the early
humoralists and ontologists. Today they ground their nosological theories about the
objective reality of disease on a sophisticated understanding of evolutionary biology and
genetics. Christopher Boorse has developed and defended the most sophisticated
contemporary version nosological naturalism. Boorse claims that the concept of disease is
grounded in the “autonomous framework of medical theory, a body of doctrine that
describes the functioning of a healthy body, classifies various deviations from such
functioning as diseases. . .ThiS theoretical corpus looks in every way continuous with
theory in biology and other natural sciences, and [is] value-free.”6 As such, Boorse
argues that diseases are recognizable against the Objective backdrop of species typical
function——a concept he borrowed and refined from 1.0. Scadding.7 Thus, the epistemic
core of Boorse’s theory of disease is statistical—— determining species typicality is a

completely empirical question. Boorse has labeled his particular brand of naturalism the

12

“biostatistical theory.”8 Disease is defined by Boorse as “a type of internal state which is
either an impairment of normal firnctional ability, i.e. a reduction of one or more

functional abilities below typical efficiency, or a limitation on functional ability caused

by environmental agents.”9
In his early writings, Boorse had drawn a gross distinction between the concepts
of disease and illness. He defined the concept of illness as a subclass of disease: those

diseases that carry with them “certain normative features reflected in the instructions of

medical practice” are considered illnesses.10 To support this framework and to Show that
disease is value—free, Boorse pointed out that we do not claim that plants or animals can
be ill or suffer from an illness. Rather we describe plants and animals as Simply being

diseased. Secondly, Boorse recognized that the ascription of illness grants the sufferer

“special treatment and diminished moral accountability?“ Thus, illness is a morally
laden concept, while the concept of disease is completely amoral. According to Boorse
(1975),

A disease is an illness only if it is serious enough to be incapacitating, and

therefore is: (1) undesirable for its bearers; (2) a title to special treatment;

and (3) a valid excuse for normally criticizable behavior.12

In his more recent writings, Boorse has refined the simple distinction between a value-
free disease and a value-laden illness, noting in part that his semantic justification was
flawed. The term ‘illness’ is in fact semantically similar to ‘Sick’ and both are terms used
to describe the state of human and nonhuman organisms. Boorse has expanded the
simpler notion of illness to include a range of grades of health, which capture the various

normative dimensions Of illness.

13

Accordingly, like disease, the theoretical concept of health should be considered
to be amoral. To determine an individual as healthy is to assess an individual’s function
in comparison to the rest of their Species. Species-typical functioning is, at base, what
grounds Boorse’s theory of health and disease. Health is thereby presumed to be the
capacity of organisms to achieve evolutionarily determined goals (i.e. survive, reproduce,
enhance fitness through kin selection, etc.). Boorse recognizes that the concept of health
is also culturally and socially determined. Depending on the context, the word ‘health’
might correspond to the opposite of illness—- that is, ‘health’ could refer to a state that is
desirable entirely because of social norms. An example of the strongly normative
definition of health is that of the World Health Organization: “Health is a state of
complete physical, mental and social well-being and not merely the absence of disease or
infirmity.”l3 Boorse claims that the theoretical concept of health, because it is ofien
confused with more practical and colloquial usage, makes it unnecessarily ambiguous.
For Boorse, determining the theoretical definition of health is his central philosophical
goal, which he claims to achieve through the evolutionarily based concepts of species

function and disease, both of which are value-free. Therefore, “the medical conception of

. . . . I4
health as absence of dIsease IS a value-free theoretical notron.”

Strong Normativism

Scholars in the philosophy, sociology, and history of science and medicine have
challenged Boorse’s naturalistic theory of disease and illness. Despite his compelling
account, they argue, the history of medicine is rife with examples of value-laden concepts

of diseases. We need only recall the antebellum disease called drapetomania (i.e. the

14

tendency of slaves to run away), the medicalization of premenstrual syndrome,

menopause, and masturbation.15 In each of these cases, particular ‘biological
dysfunctions’ were supposedly identified and determined to be the root cause of the
disorders in question. In the case of drapetomania, Slaves were said to have a biologically
based tendency to abscond, which was directly related to physiological features such the

color of “the negro’s brain and nerves, the chyle and all the humors, [which] are tinctured

with a shade of the pervading blackness.”l6 The process of medicalization of both PMS
and menopause arguably revealed particular gendered assumptions about the proper role
of women in society and within the family; assumptions that I will more fully articulate
with my examination of the borderline personality disorder. As we will see in cases of
personality disorders, such as borderline, we find marked deficiencies in the functional
status of a stable, rational, and unified concept of the self as idealized by Kant. The
assumption that the female self is unstable has also served as the basis for the invention
of other mental illnesses like kleptomania by offering a way to explain deviant behavior
by well-to-do middle-class women.17 The upshot, feminist philosophers argue, is that
psychiatric categories place women in a double bind, where attaining health is only

possible through deference to (male) authority and a medical diagnosis is bestowed upon

18
those women who do not conform.

Along similar lines, disability scholars have clarified the distinction between the
social and biological models of disability. Activist scholars reject naturalistic accounts Of
disability, claiming instead that disability is a social construction that marginalizes people
whose bodies or minds do not meet the standards of the status quo. They claim the

biomedical model of disability is SO pervasive it has led to what Amundson calls the

15

standard view: the idea that being disabled is a biological deficiency that is obviously bad
for one’s quality of life.19 This view is also entrenched in philosophical literature on
quality of life. Interestingly, however, empirical evidence has exposed the paralogism of
the standard view: disabled people feel their quality of life is only slightly less than
nondisabled people, and it is much higher than what nondisabled people would have ever
guessed.

This revelation lends credence to the social constructionists’ call for
accommodation and acceptance of the full range of human ability. Their basic Objection
to naturalism is that species typical firnction is an irrelevant determination since
variation—-— even in instances of statistical outlierS——— is an essential part of a species’
evolutionary history. Statistical curves might describe the numbers of individuals With a
particular trait, but do not capture the importance of the diversity within those traits.
Additionally, the cut-off points of typicality and normalcy are completely arbitrary and
rooted in social ideals about types of bodies and minds.

Although below I will describe H. Tristram Engelhardt as moderate normativist,
his early theory, described in an influential series of articles and lectures, reveals the
markings of an unabashed strong normativist. In one of his most well known articles,
Engelhardt draws on the historical and sociological construction of the “disease” of
masturbation to argue that the concept of disease is ultimately value—laden.20 He argues
that diseases, whether somatic or psychological, are not objectively determinable
biological states but, instead, always include an important moral dimension. In

Engelhardt’s words,

16

...although vice and virtue are not equivalent to disease and health, they

bear a direct relation to these concepts. Insofar as a vice is taken to be a

deviation from an ideal of human perfection, or “well-being,” it can be

translated into disease language...This shift is from an explicitly ethical

language to a language of natural teleology. A ‘disease entity’ operates as

a conceptual form organizing phenomena in a fashion deemed useful for

certain goals. The goals, though, involve choice by man and are not

objective facts, data ‘given’ by nature. They are ideals imputed to nature.

The disease of masturbation is an eloquent example of the role of

evaluation in explanation and the structure values give to our picture of

reality.
As we will see, there is no shortage of disturbing examples of the medicalization of
(im)morality or social deviance. From race and gender to sexuality and disability, it is
arguably possible that any power structure in society can be reinforced or expanded
through the process of medicalization. Thus, a key problem for my pragmatic theory will
be distinguishing between instances of nefarious medicalization and arguably ethical
instances of medicalization—defined in terms of benefit to patients, families, and the
community. For now, the important point is that the above examples of medicalization
are often presented as paradigm cases in support of normativism and, as such, are used to
argue strongly that it is impossible to create a nosology that is not inherently normative,
political, or otherwise socially influenced.

An important question now emerges: Do these examples of socially constructed

diseases offer convincing evidence that the concepts of health, disease, and illness are

17

value-laden? One could reasonably argue that these cases of medicalization do not
provide enough evidence that diseases are a wholly value-laden or socially constructed.
Rather, these “diseases” are simply cases in which a correct objective concept of disease
was misused or abused. Ironically, many of the cases used by strong normativists seem to
actually support the naturalist position, since the recognition of pseudodiseases

presupposes the existence of an objective set of criteria that expose the absurdity of

“diseases” like drapetomania?! This is to say that without the objective facts of biology,
anything could be construed as a disease. And the scientific “facts” were Simply false in
the egregious cases cited by strong normativists. In his rebuttal, Boorse makes exactly
this point. He says, “Engelhardt’s essay shows that if we abstract, as he does, from all
questions of truth and falsity, then masturbation and drapetomania were Victorian

diseases. Equally, if we abstract from all questions of truth and falsity, then cows jump

22
over the moon.”

Additionally, strong normativists who rely exclusively on historical examples
seem to rely heavily on the important insights of Ludwig Fleck and Thomas Kuhn, both
of whom argued that social values permeate all of science rendering the entire enterprise
politically driven. In so doing, proponents of this strain of strong normativism fall prey to
a sort of genetic fallacy by claiming that because the social structures of science and
medicine are riddled with social and political values, the products of those enterprises
(such as nosologies) must also be merely social and political artifacts. As such, these
products carry with them the social values of a particular group of researchers and may
influence or conflict with the views of other factions. Engelhardt articulates this point

stating,

18

...as the history of medicine has shown, medicine’s explanatory goals are
pursued by particular groups of scientists with particular understandings of
what should count as the proper rules of evidence and inference, which
may conflict with lay understandings of disease and treatments or the
understandings of other investigators. To resolve such controversies,

those involved will need to make clear what the rules of evidence out to be

accepted and why.23
Although, as I have mentioned, there are limits to the logic of using historical cases as
evidence of the true ontology of disease, Engelhardt’s insight will become important
when we discuss the pragmatic theory of mental illness, which I will frame as an overtly
normative extension of naturalist theories of mental illness. In order to construct an
ethical pragmatic theory of mental illness we will need to describe how to handle the
latent values that might drive scientific research for good or for ill, and make transparent
our pragmatic goals about why and how categorizing personality disorders occurs.

In contrast to appeals to historical and sociological evidence, other normativists
like Peter Sedgwick take a more metaphysical tack by arguing that disease and illness
are, quite simply, not natural kinds. Sedgwick claims,

There are no illnesses or diseases in nature... The fracture of a

septuagenarian’s femur has, within the world of nature, no more

significance than the snapping Of an autumn leaf from its twig; and the
invasion of a human organism by cholera-germs carries with it no more

the stamp of “illness” than does the souring of milk by other forms of

. 24
bacterra.

l9

Here Sedgwick draws upon a basic fact/value distinction to argue that the only reason
diseases matter is because of their impact on human needs and desires. Boorse, however,
would quickly respond by contending that a broken femur is a disease—~apart from its
impact on human desire—simply because it impairs the functioning of the leg, which
likewise impairs the function of the individual.

A couple other strong normativists are worth mentioning by way of introduction.
Caroline Whitbeck has argued that diseases are not value-neutral, but are the result of a
frustration Of what people expect to be able to do in a particular culture. Thus, those
states that constitute diseases “depend on a value judgment of the societal group, rather
than upon either the judgment of the person afflicted or simply the judgment of the

professional whom the society has charged with developing and applying therapeutic

measures.”25 In a similar way, George Agich rejects Boorsian naturalism. He claims that
disease is value-laden insofar as disease constitutes a limitation on the sufferer’s freedom.
For Agich, disease is not simply a biological fact, but rather a socially embedded and
complex limitation of personal freedom.26 Agich’s pragmatic theory of illness will
supply a starting point for my own pragmatic model of mental disorder.

In the end, strong normativism, whether it is based on historical and sociological
study or on the careful clarification of philosophical distinctions, seems to remain
vulnerable to Boorse’s arguments and counterarguments. Perhaps more moderate forms
of normativism, which grant the existence of brute facts of nature while also recognizing
the permeation of values in assessing those facts, will provide a more convincing I
framework to satisfy the common intuition that health, disease, and illness are in some

Way value-laden concepts.

20

Moderate Normativism & Hybrid Theories of Disorder

Between the strong normativist and naturalist positions lies an ensemble of
moderate normativist and hybrid positions. In his more recent writings, Engelhardt, while
rejecting Boorsian naturalism completely, offers a more moderate normative theory of
disease and illness. He clearly recognizes the roles played by social values, religion, and
law in constructing medical realities such as diseases. These roles are reflected in the SO-
called ‘four languages’ of medicine that demarcate the domains of discourse and reality
within which medicine Operates. The first of these languages deals with “evaluative

assumptions regarding which functions, pains, and deformities are normal in the sense of

9,

proper and acceptable. 2 Engelhardt vigorously argues that assessments of dysfunction
or species typicality are highly problematic because they fail to account for a variety of
important evolutionary concerns such as species diversity and inclusive fitness. He
accepts Boorse’s naturalism as well suited for the unapplied biological sciences such as
zoology, but claims it is woefully inadequate for medicine, which aims toward particular
goals determined by physicians, patients and society.

Other forms of moderate normativism take a different tack by describing diseases
in terms of disorders in the integrity of the body or mind that inhibit so-called prudential

functions (i.e., those things that matter to attaining prudential values such as the

avoidance of pain, death, and security) or that diminish a person’s ability to achieve vital

goals.28 For Clouser, Culver, and Gert what makes a disease or injury a unique kind (or
malady) is that there is an undesirable abnormality— defined in both natural and social

tenns—— that exists without a distinct sustaining cause. On this model, a disease is one

21

kind of malady, existing alongside traumatic injury, lesions and other defects.29 All
diseases are maladies but maladies are not necessarily diseases. Examples of nondisease
maladies would include injuries or other evils that lack distinct sustaining causes. Simply
put, a disease is a species within the genus malady. Although Clouser, Culver, and Gert

claim that their concept “considerably lessens the influence of ideologies, politics, and

self—serving goals in manipulating malady labels” they do admit to its vagueness.30 I

consider malady to be a hybrid theory Of disease because “it can be universal and

objective and at the same time have values as an integral part.”31

Jerome Wakefield has developed a moderate form of naturalism in his influential

hybrid theory Of mental illness.32 Wakefield has tried, in his own ambitious words, “to

construct a more adequate analysis and to resolve the fact/value debate” vis-a-vis the

concepts of health and disease.33 TO do this, Wakefield offers his two-part concept of
harmful dysfunction used to determine a disorder. He begins by describing function in a
very specific medical sense:

Function and dysfunction in the medical sense refer, in the first instance,

not to the quality of a person’s performance in a given environment but to

whether mechanisms within the person are performing or failing to

perform functions they were designed to perform.34
Similarly to Boorse, Wakefield goes on to argue that biological functions are completely
value neutral, while the degree to which these dysfunctions are harmful include
normative and value-based judgments. Once a dysfunction is considered harmful, it is
called a ‘disorder’. In other words, healthy cells, tissues, organs, and systems perform a

function determined by evolution, which when disrupted and determined to harmful, can

22

be described as a disorder. Evolutionary biology determines firnction or dysfunction,
while social values and norms determine if an instance of dysfunction is harmfirl or not.
Wakefield uses the term internal mechanisms to refer to both physical structures and
organs and mental structures and dispositions. Wakefield therefore sets out to describe a
unified concept of disorder- one that will be equally applicable for understanding both
mental disorder and physical disorder.

To construct the concept of disorder, Wakefield first provides a detailed
description of how a determination of dysfunction can be derived from evolutionary
theory. Essentially a mechanism’s usefulness toward the goal of survival and
reproduction of an organism—or enhancing an organism’s inclusive fitness—determines
that mechanism’s natural function:

In brief, those mechanisms that happened to have effects on past organs

that contributed to the organisms’ reproductive success over enough

generations increased in frequency and hence were ‘naturally selected’

and exist in today’s organisms.35
It is important to recognize an organ has many effects, but, according to Wakefield, only
one function. Although the heart makes a sound when beating, its firnction is to pump
blood, not create sound. His theory of function must be robust enough to distinguish
between the miscellaneous effects of organs and their teleologically defined function.
Wakefield claims the biological sciences give us the methods and tools to ascertain
function and draw this distinction. Wakefield defines natural function as “an effect of the

organ or mechanism that enters into an explanation of the existence, structure, or activity

”36

of the organ or mechanism. To the extent that function and dysfunction are purely

23

scientific assessments, such assessments are enhanced and sharpened with technological
advances. At present, Wakefield thinks we have a substantial understanding of natural
function based on our knowledge of anatomy, physiology, and genetics. However in the
context of mental disorders, Wakefield acknowledges that our knowledge of mental
mechanisms is too deficient at present to clearly demarcate biological dysfunction. He
says,
this ignorance about the detailed nature and causal histories of mental
mechanisms...makes it. . .necessary to rely on functional explanations
based on inferences about what mental mechanisms are probably designed
to do. In this respect, we are now at a stage of understanding that is
comparable in some ways to the position of ancient physicians who had to
rely on similar inferences in judging physical disorder...as we learn more
about the naturally selected functions of mental mechanisms, our

judgments about dysfunctions will become correspondingly more

confident.37
As we will see, Wakefield’s speculation that our dearth of scientific information on the
etiology of mental illness will eventually be resolved is one of the most problematic
aspects of his theory that the pragmatic theory I develop will try to address.
The second part of Wakefield’s theory entails a description of harm. He
acknowledges that it is tempting to justify a concept of disorder on Simply dysfunction,
thus fulfilling the nonnormativist aspiration for a value-free framework of disease and
disorder. Wakefield understands this as impossible; he explains that a dysfunction must

cause harm to a person and, admittedly, this harm might be based on cultural standards of

24

what is valued or disvalued. Likewise, the harm requirement might not be met for certain
dysfunctions, thereby exempting them from disorder status. For example, the harm
requirement explains why “albinism, reversal of heart position, and fused toes are not

considered disorders even though each results from a breakdown in the way some

. . . . ,,38
mechanism 15 desrgned to fimctron.

In contrast to the theories presented above, Marc Ereshefsky claims that

conceptual consensus is impossible because normativism, naturalism, and hybrid models

are all ultimately incoherent and the current debate is not productive.39 He suggests
jettisoning the normativism-naturalism distinction altogether and looks instead to so-
called state descriptions (objective physiological measurements) and corresponding
normative claims (a claim that the state is good or bad for a person). State descriptions
differ from descriptions of function in that they are empirical reports of current
conditions that avoid appeals to concepts of ‘natural’ or ‘normal’. Moreover, state
descriptions have nothing to say about whether the state in question is either ftmctional or
dysfunctional. According to Ereshefsky, instead of defining health and disease as natural
kinds or normative constructions, state descriptions provide more conceptual promise
because they pinpoint the phenomena in question. A normative assessment then provides
an account of whether it is valuable or not. This method is advantageous because, as
Ereshefsky claims, state descriptions aim to avoid overt normative claims about
normalcy. Moreover,
. . .there are three reasons for using the distinction between state
descriptions and normative claims. First, talking in terms of state

descriptions and normative claims clarifies discussions Of controversial

25

medical cases. Second, by framing debates in such terms we get to the
issues that matter in medical discussions, thus rendering the terms ‘health’
and ‘disease’ superfluous in such discussions. Third, using the distinction

between state descriptions and normative claims avoids the problems

facing the major approaches to defining ‘health’ and ‘disease’.40

Ereshefsky’s point makes intuitive sense. By shifting attention away from theories that
are dependent on more firndamental metaphysical distinctions, Ereshefsky has indicated
he wishes to focus on the particular conditions in question. Thispis a promising start
toward a more pragmatic theory of health, disease, and illness. However, Ereshefsky
points to the possibility of ascertaining and disentangling the objective reality of
particular states from normative claims pertaining to those states. And while Ereshefsky
argues that his proposal advances the debate beyond the traditional lines of naturalism
and normativism, the distinction between state descriptions and normative claims will
ultimately become confused because, as he admits,
Many state descriptions in the medical and biological sciences
undoubtedly rely on implicit normative assumptions...State descriptions,
contain no explicit normative components. By using the distinction
between state descriptions and normative claims we make normative
assumptions as Obvious as possible. Once values are seen as entering a
discussion, any talk of values is highlighted as a ‘normative claim". that
way, discussions concerning values will be explicitly normative. State

descriptions will never be completely value-neutral, but we can do our

best to label value judgments as such when they are identified.41

26

And although Ereshefsky wishes to shine a light on the implicit values of our conceptual
claim about disease and dysfunction, we nonetheless seem to be baCk to square one: an
attempt to distinguish between objective facts and social values that has come to define
the tension surrounding the core concepts of medicine.
In any case, I will argue that for mental illnesses—and particularly personality
disorders—~Ereshefsky is on to something important and that his call for normative
transparency, much like Engelhardt’s, is correct. In describing my pragmatic model of
mental disorder, I hope to provide a set of key ethical considerations that will add relief
to the normative assumptions being made about a particular set of questionable
behaviors. Insofar as personality disorders qua constellations of particular behaviors
constitute state descriptions, Ereshefsky’s theoretical background is helpful. In the
meantime, let us continue our survey of the conceptual landscape of mental illness,

particularly related to theories that are deeply skeptical mental illnesses exist at all.

The Social Construction of Mental Illness & Anti-Psychiatry
Notwithstanding the promise of hybrid theories of disease and disorder, the
ongoing debate between normativism and naturalism continues and is most obvious in
psychiatry. Several theories of illness posit that cases of what we now consider to be
mental illnesses are purely social constructions and have no necessary basis in biological
dysfirnction. One important strain of social constructionism is exemplified by the
complementary writings of Georges Canguilhem and his student Michel Foucault.
In his influential work, Le Normal et le Pathologique, Canguilhem laid the
foundation for understanding the distinctions grounding the practice Of medicine are

borne out of the latent values Of the structures Of science, particularly in attempts toward

27

a definition of normal through experimental work in physiology. While his core set of
arguments target Claude Bernard’s experimental naturalism, Canguilhem seems also to
anticipate the development of Boorse’s philosophical naturalism, which will arrive within
two decades. As cited by Tiles, Canguilhem offers the following prescient insight:
If it is true that the human body is in one sense a product of social activity,
it is not absurd to assume that the constancy of certain traits, revealed by
an average, depends on the conscious or unconscious fidelity to certain
norms of life. Consequently, in the human species, statistical frequency
expresses not only vital, but also social normativity. A human trait would
not be normal because frequent, but frequent because normal, that is,

normative in one given kind of life, taking these words 'kind of life’ in the

sense given to them by human geographers. 42
In essence, Canguilhem argues that normalcy is impossible to define on strictly scientific
or statistical bases. Expressions ofnormalcy—even the most ostensibly Objective
biological expressions—always include values imparted from social structures and ways
of life. This perspective comes from Canguilhem’s unique medical epistemology, in
which both empirical science (experimental medicine) and rationalism are inextricably
linked aspects of medicine. Thus, for Canguilhem, the concepts of health and disease are
not sufficiently explained in terms Of mathematical or statistical data. Rather, health,

disease and normalcy are all comprised of an organism’s capacity for adaptability and

capacity to flourish. They are qualitative and interdependent concepts.“
Canguilhem’s work set the stage for Foucault’s genealogical analysis of madness,

which aimed to expose the power and social dynamics from which particular forms of

28

mental illness were Objectified. In Madness and Civilization, Foucault presents a
historical-philosophical portrait of the developments that led to the cultural construction
of mental illness, as we now understand it. He argues that through a series of
exclusionary institutions (e.g. the Ship of fools and the so-called “Great Confinement” of
lunatics in Parisian asylums), madness took the place of leprosy and other socio-medical
blights. The justification for exclusion and confinement no longer came from the
symptoms of leprosy but from the characteristic “Unreason” of the madman, which
became recognizable only after the Enlightenment standard of reason had been firmly
established:
It is not on this horizon of nature that the seventeenth and eighteenth
centuries recognized madness, but against a background of Unreason;
madness did not disclose a mechanism, but revealed a liberty raging in the
monstrous forms of animality. We no longer understand unreason today,
except in its epithetic form: the Unreasonable. . .F or classical man,

madness was not the natural condition, the human and psychological root

of unreason; it was only unreason’s empirical form.‘44
In fact, the central themes presented in Madness and Civilization seem to be a reflection
of Foucault’s doctoral research on Kant’s Anthropology from a Pragmatic Point of View.
In Anthropology, Kant sets out a very crude (by today’s standards) empirically based
psychological nosology in which he distinguishes between very broad categories of
mental illness such as melancholia and derangement. And it should come as little ‘
surprise that Kant’s nosology relies upon an assessment a person’s capacity for correct

reasoning.

29

In his Introduction to Anthropology, which was a complementary thesis written
alongside Madness and Civilization, Foucault recognizes Kant’s central point in

Anthropology that “man is neither a homo natura, nor a purely free subject; he is caught

by the syntheses already operated by his relationship to the world.”45 This intermediary
position of mental illness- residing somewhere between a natural and an artificial kind-
which, according to Foucault, is articulated by the most paradigmatic of Enlightenment
thinkers should give us pause in efforts to strictly define mental illness in purely
naturalist or purely normativist terms. Though it is widely believed that Kant rejects the
promise of both rational (i.e. metaphysics) and empirical psychology to answer his core
philosophical questions such as “What is the Human Being?” and its corollaries

concerning idiosyncrasies of the human mind, he does recognize the practical value of

categorizing particular behaviors according to pragmatic concerns.46 I should note that
the intellectual thread that begins with Kant’s pragmatic anthropology of mental illness
runs through (and has to some degree inspired) the pragmatic theory of mental disorders I
will soon present.

In a continuation of Foucault’s reporting of “The Great Confinement” and thesis
that mental illness supplanted leprosy, Thomas Szasz similarly argues that the concept of
mental illness locates its roots in witchcraft, eventually superseding witchcraft as a
scientifically ‘valid’ version of it.47 This thesis is clearly articulated in Szasz’s 1970
book, The Manufacture of Madness, in which he argues that institutional psychiatry- that
branch of psychiatry that facilitates the involuntarily commitment of mentally ill patients-
is nothing more than a modern day version of the Inquisition. As is well known, in his

seminal book, The Myth of Mental Illness, Szasz describes mental illness as nothing more

30

than metaphor or an artifact of language.48 As a result, he argues that both the insanity
defense and forced incarceration are nothing more than devices used to either exculpate
bad behavior or violate individual liberty.

Szasz’s decades-long refusal to recognize a natural reality of mental illness is an
example of strong normativism or social constructionism in psychiatry. But by the same

token, by claiming what are conventionally considered mental illnesses are reducible to

somatic disease, Szasz is really a strict naturalist for disease more generally.49 We will
return to Szasz when we consider the blameworthiness of patients with personality

g disorders and whether they suffer from mental illness or are simply vicious. We will also
address Szaszian objections to pragmatically motivated ascriptions of mental disorder.
Suffice it to say, Szasz’s libertarian critique of modern psychiatry has provoked heated
debate within mainstream psychiatry and among the lay public about overreach in the
medicalization of human behavior.

With that in mind, I should note here that both Foucault’s archeology of madness
and Szasz’s rejection of mental illness have both been roundly criticized as nothing more
than historical fiction interlaced with philosophical argumentation. Roy Porter, in
particular, has criticized both accounts as facile:

It would be simplistic to cast the rise of institutional psychiatry in crudely

functional or conspiratorial terms, as a new witch-hunt or a tool of social

control designed to smooth the running of emergent industrial society.

The asylum solution should be viewed less in terms of central policy than

as the site of myriad negotiations of wants, rights, and responsibilities,

between diverse parties...The confinement (and subsequent release) of a

31

sufferer was commonly less a matter of official fiat than the product of

complex bargaining between families, communities, local officials,

magistrates, and the superintendents themselves. The initiative to confine

might come from varied sources; asylums were used by families no less

than by the state; and the law could serve many interests.50
In resonance with Porter’s point, I contend that we should maintain a critical perspective
on the social constructionists’ evidence as being perhaps less literal historical reports but
rather more of a set of embellished episodes that are meant as cautionary tales. At least
this is how I will interpret much of the anti-psychiatry and social constructionist
arguments. In discussions related to the historical-social underpinnings of borderline
disorder, this point will become clear and important. The historical renderings, metaphors
and tropes used to describe the behavior of the borderline woman should be seen as such,
and will serve as a set of anti-paradigms in my development of an ethical pragmatic

theory mental illness.

Conclusion

To end this chapter, I wish to preview what a pragmatic theory of mental illness
might look like in comparison to the standard theories of health, disease and illness
presented above. I wish to highlight four important and interrelated dimensions to the
pragmatic theory of mental illness that set it apart from the standard theories. First,
although it will be an extension of a hybrid account of disorder that is built upon a
naturalistic core, a pragmatic theory of mental illness need not be based on a deeper
metaphysical grounding about the “true” nature of health and disease. This is to say,

determining a biological dysfunction will not be a necessary condition for the ascription

32

of mental illness. What shall happen, as I develop this theory, is that the naturalistic core
of cases like depression and schizophrenia will provide analogical starting points for
marking out instances of social dysfunction. But then the naturalistic core will fade into
the background. Social dysfunction will be sufficient (with caveats, of course) to define
mental illnesses such as personality disorders. Thus, the pragmatic theory seeks to move
beyond the incommensurable metaphysical arguments about health, disease and illness in
a move that mirrors Kant’s in Anthropology.

Second, a pragmatic theory of mental illness will be transparent in the way
sociocultural values are integrated and used. Thus, it will be overtly normative. It
therefore becomes imperative that a pragmatic theorist of mental illness straightforwardly
reveals her practical goals and that the efforts of professional bodies to create disease
categories be critically examined according to a systematic analysis. Third, the pragmatic
theory of mental illness recognizes the importance and reality of suffering—whether it is
of the mentally ill person, their family and friends, or the community. Further, that the
suffering caused by mental illness is best treated by medical professionals and within the
domain of medicine. Fourth, recognizing its fallibility, the pragmatic theory of mental
illness will be subject to constant review and revision, as it should reflect the values of a
just and decent democratic society.

In conclusion, the goal of this chapter was to map the conceptual landscape of the
concepts of health, disease and illness to contextualize theories of mental illness. As we
have seen, we can distinguish broadly between naturalistic theories and normative
theories of disease, from which derivative conceptions of mental illness emerge. Hybrid

theories and moderate normative theories attempt to integrate particular objective

33

scientific realities with recognition of the important role played by social values in the
creation of diagnostic categories. Social constructionists and anti-psychiatry proponents
argue that mental illness is nothing more than the singling out of socially inconvenient or
deviant behavior and, as such, mental illnesses are social constructions, which are aimed
at curtailing disruptive behavior or, worse, created to justify the incarceration of people
who present as threats to political or moral authorities. As we will see in the Chapter 3,
recent pragmatic theories of health, disease and illness provide a starting point for
extending the discussion beyond irreconcilable debates about the ontology of mental
health and illness. We will find, however, that these pragmatic theories provide little in

the way of needed ethical resources for their application.

 

1. For an excellent account of the diverse set of explanations and theories, including a tabular
summary of these concepts, see: Bjorn Hoffman, "Complexity of the Concept of Disease as Shown
Through Rival Theoretical Frameworks" Theoretical Medicine 22, no. 3 (2001): 21 1-236. The medical and
social models of disability are described by Ron Amundson, "Disability, Ideology, and Quality of Life: a
Bias in Biomedical Ethics," in Quality of Life and Human Difference, ed. David Wasserrnan, Robert
Wachbroit, and Jerome Bickenbach (New York: Cambridge University Press, 2005), 101-124.

2. Campbell et al. (as cited by Hofmann); Reznek (as cited by Hofmann); Jaspers (as cited by
Hofmann)

3. Bjorn Hofmann, 2001 (See 11. 1); Marc Ereshefsky, "Defining 'Health' and 'Disease'," Studies in
the History and Philosophy of Biological and Biomedical Sciences 40 (2009): 221-227.

4. Meta-analyses of theories of health and disease, such as Marc Ereshefsky’s, use this tripartite
distinction. See: Ereshefsky, 2009 (See 11. 3)

5. Virchow stated that “[t]his view is clearly ontological...an ens morbi does exist, just as there is
an ens vitae; in both cases a cell or a cell complex is entitled to be so named.” Rudolf Virchow, "Three
Selections from Rudolf Virchow," in Concepts of Health and Disease, ed. Arthur Caplan, H.Tristram
Engelhardt, and James McCartney (Reading. MA: Addison-Wesley, 1981), p. 191. Vichow distinguished
the cause (causa morbi) from the ens. Engelhardt, 1981 claims that the ontological concept refers to both a
thing (ens) and a logical type. James A. Marcum, An Introductory Philosophy of Medicine: Humanizing
Modern Medicine,(New York: Springer, 2008), p. 65.

6. Christopher Boorse, "On the Distinction Between Disease and Illness," Philosophy and Public
Aflairs 5, no. I (1975): 55-56.

8 7. JG. Scadding, ”Diagnosis: the Clinician and the Computer," Lancet 2, no. 7521 (1967): 877-
82.

8. Christopher Boorse, "A Rebuttal on Health," in What is Disease? ed. James M. Humber and
Robert F. Almeder (Totowa, N.J.: Humana Press, 1997), 3-134.

9. lbid., 8.

10. Boorse, 1975, 57.

ll. lbid., 56.

12. lbid., 61.

13. World Health Organization, Preamble to Constitution of the World Health Organization,

Geneva: WHO, 1948.

34

 

14 Christopher Boorse, "Health as a Theoretical Concept," Philosophy of Science 44, no. 4

(1977), 542.
15. See: Samuel A. Cartwright, "Report on the Diseases and Physical Peculiarities of the Negro

Race, " in Health, Disease, and Illness: Concepts in Medicine, ed. Arthur L. Caplan, James J. McCartney,
and Dominic A. Sisti (Washington, DC: Georgetown University Press, 2004), 28-38; H. Tristram
Engelhardt, "The Disease of Masturbation: Values and the Concept of Disease," in The Concepts of Health
and Disease, ed. H. Tristram Engelhardt and James J. McCartney (Reading, MA: Addison-Wesley, 1981),
267-280; J. T. Richardson, "The Premenstrual Syndrome: A Brief History," Social Science and Medicine
41 no 6(1995): 761-767; Frances B. McCrea, "The Politics of Menopause: The 'Discovery' of a

Deficiency Disease," Social Problems 31, no. I (1983): 1 11-123.

16. Cartwright, 2004, 29.
17 Elaine S Abelson, "The Invention of Kleptomania," Signs 15, No. l (1989)2123-l43.

18. Marilyn Frye, The Politics of Reality: Essays in Feminist Theory (Freedom, CA. Crossrng
Press 1983) Susan Sherwin, No Longer Patient: Feminist Ethics and Health Care (Philadelphia: Temple

University Press, 1992).
19. Ron Amundson, 2005.

20. Engelhardt, 1981.
21. Whales are obviously not fish, though they were long classified as such. Similarly, the

naturalist would argue, drapetomania was never a disease though it was classified as one.

22. Boorse. 1997, 77.
23 H Tristram Engelhardt, The Foundations of Bioethics (New York: Oxford University Press

1996), 218.
24 Peter Sedgwick, Psychopo/itics (New York: HarperCollins Pub1ishers, 1982), 30.

25. James A. Marcum. 2008, 72.

26. lbid., 71.

27. Engelhardt, 1996, 196.
28 Joseph Margolis, “The Concept of Disease” in The Concepts of Health and Disease, ed. Arthur

Caplan, H. Tristram Engelhardt, James McCartney (Reading, MA: Addison-Wesley, 1981), 561 577
29 K Danner Clouser, Charles M. Culver, Bernard Gert, “Malady: New Treatment of Disease

Hastings Center Report 11, no. 3(1981): 29—37.
30. lbid., 36.

31. lbid.
32 Jerome C. Wakefield, “The Concept of Mental Disorder: On The Boundary Between

Biological Facts and Social Values,” American Psychologist 47, no. 3 (1992): 373—388

33.1bid, 374.
34 Jerome C Wakefield, “Aristotle as Sociobiologist: The Function of a Human Being Argument

Black Box Essentialism, and the Concept of Mental Disorder,” Philosophy, Psychiatry, and Psychology 7

no. 1 (2000): 20.
35. Wakefield, I992, 383.

36. lbid., 382.

37. lbid., 383.

38. lbid., 384.

39. Ereshefsky, 2009, 226.
40. lbid., 226.

41. lbid., 227.
42. Mary Tiles, "The Normal and Pathological: The Concept of a Scientific Medicine," The British

Journal for the Philosophy of Scrence 44, no. 4 (1993): 736-737.
43. Richard Horton, “Georges Canguilhem: Philosopher of Disease, ” Journal of the Royal Society

OfMedicine 88, no. 6 (1995): 316—319.
44. Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason (New

York: Random House, 1965), 83.
45 Michel Foucault, Introduction to Kant ’5 Anthropology, trans. and ed. R0931“) Nigro, trans.

Kate Briggs (Los Angeles, CA: Semiotext(e), 2008.), 54.
46. See Immanuel Kant, Critique of Pure Reason, A34 1 /B399.

35

47. Thomas Szasz has argued he has been mischaracterized as proponent of “anti-psychiatry” most

recently in his book Antipsychiatry: Quackery Squared (Syracuse, NY: Syracuse University Press, 2009). 1
will, nonetheless, use this term to describe Szasz’s brand of strong constructionism of mental illness.
48. Thomas Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct,

New York: Paul B. Hoeber, I961.
49. This is why there is confusion about how to classify Szasz. “Many of those who point to

examples of the abuse of disease concepts are pointing out the way these are contaminated by value

assumptions. But it may often be unclear whether they are objecting to the specific values at work, or to the

idea that values should play any role in the ascription of disease.” (Tom Tomlinson, pers. comm, 2010)
50. Roy Porter, Madness: A Brief History, (New York: Oxford University Press, 2002), 98-99.

36

CHAPTER 2

THE CONCEPTS OF BIOLOGICAL & SOCIAL (DYS)FUNCTION

Introduction

In this chapter, I will begin by drawing a key distinction that, I will then argue,
necessitates the move from a naturalistic theory of mental illness to a pragmatic theory.
The key distinction to be drawn is between two kinds of function concepts: biological and
social. It is first necessary to distinguish between function concepts to then justify the
ontological commitment I will be making in drawing a second, but related, distinction
between two broad categories of mental illness: core cases and boundary cases of mental
illness. I will exemplify this second distinction using the case of schizophrenia to
illustrate core cases and the borderline personality disorder to describe boundary cases.

It is crucial to talk about function first, because I will argue that, at least with

respect to core cases of mental illness, Boorse’s biostatistical theory of disease (BST) and

Wakefield’s harmful dysfunction (HD) theory are theoretically satisfactory.1 In
particular, Boorse’s concept of biological function, which grounds his BST has been
exceptionally resilient to critique. Thus, Boorse’s and Wakefield’s theories provide a
sufficient explanation to justify medical intervention in core cases of mental illness.
However, in order to eventually show why a pragmatic theory is needed for boundary
cases of mental illness, I will explain why I believe these naturalist-hybrid theoretical
models ultimately fail in pinpointing the essence of social dysfunction, which by ,
definition is a marker of a personality disorder. This is to say, naturalist or hybrid theories
fail to provide sufficient justification for treating personality disorders as medical

conditions. I will be arguing that personality disorders should count as medical conditions

37

and that for these boundary cases of mental illness a pragmatic theory offers the kind of
explanatory power needed to categorize constellations of socially dysfunctional behavior
as mental illnesses. This is all meant to lay the foundation for my work in chapter 3,
where I introduce other pragmatic theories of mental illness and begin to detail the
pragmatic theory I offer, which turns on the concept of social dysfunction.

Thus, the goal of this chapter is twofold: (l) to explain the key distinction
between core and boundary cases of mental illness by defining them in terms of
biological and social function, respectively, and (2) to being illustrate these function
concepts with regard to core and boundary cases. My aim is to set the stage for my
pragmatic theory of mental illness by showing why personality disorders ought to be
included as mental illnesses on the grounds that they represent a particular kind of social

dysfunction and that naturalist models are too limited for this purpose.

Pluralism & Function Concepts

As Kitcher has argued, fundamental philosophical concepts such as ‘species’ or

‘function’ should be understood in terms of what he calls pluralistic realism.2 This simply
means that theoretical understandings and applications of the concept of function will be
(and should be) different for each particular subdiscipline of biology and community of
biologists. Likewise, dysfunction will mean something very different to the ethologist,
cladist, or ecologist as it might for the virologist or cell biologist. This is not to say
‘function’ is an altogether relative concept. A virtue of a good theory of function is that it
should remain constant and should provide the necessary scope to handle a variety of

cases-from the function of artificial devices to organic processes. But instances of what

38

is considered to be a relevant function or dysfunction might vary across the reference
class a biologist is examining. It is in the spirit of Kitcher’s pluralistic realism that I
focus on those functional concepts that seem to be most germane to naturalistic nosology.
And so, I wish to restrict my discussion of function to those theories that underpin
.Boorse’s naturalism and will leave aside complicated questions related to functional
statements about human artifacts or more fine-grained evolutionary arguments about
improvised fimctions known as exaptations. Moreover, my commitment to pluralistic
realism on function will be important as we begin to examine the unique dimensions of
dysfunction represented by the personality disorders.

As I mentioned above, I believe Boorse’s BST is adequate in dealing with somatic
disease and core cases of mental illness. To defend this claim, I will first articulate
Boorse’s concept of fimction as it pertains to both somatic and psychological disease. Of
course, because species typical function is the conceptual foundation of his concept of
disease, an assessment of the concept of function is essential in determining what should
be included in the naturalist’s ontology of disease, disorder, and illness. If Boorse’s
concept of function is ftmdamentally flawed, his BST will be shown to be hopelessly
misguided.

As I mentioned in Chapter I, Boorse’s concept of species typical function is not
without its problems; so I will address the more significant objections to this concept and

then offer replies on Boorse’s behalf. Again, my immediate goal here is to persuade you,
the reader, that a level of theoretical adequacy is met by Boorse’s theory for core Cases of
mental illness and prepare to show that the theoretical limitations of the concept of

function are too narrow to provide a rich account of the ontological status of personality

disorders. Let us first begin with a survey of the concept of function as it is typically
applied to cases somatic disease qua organ or cellular dysfunction and then we will look

at how it applies to core cases of mental pathology.

Biological Function

Arguments about the nature of ‘ftmction’ locate their roots in ancient philosophy.
Ever since Aristotle’s zoological studies, the concept of biological function has been
bound up with teleology in one sense or another. That is, the function of a cell or organ,
for example, has been typically defined in terms of an activity that contributes toward the
goal of the larger system within which the cell or organ is situated. As is well known,
according to Aristotle the telos——or final cause——of the individual animal was specific to
that animal and implied no external directedness or purposefulness. Rather, the final
cause of an animal is simply to become an individual of the particular species. Indeed, in
the lexicon of Aristotelian causes, the telos Of a natural thing is also part of its formal
cause and not simply its final cause. In other words, the form of the cell or organ is a
reflection of its final cause and vice versa. For example, the form of the eye is as it is for
the function of sight. Likewise, the function of the heart is to pump blood, and not to, for
example, make its characteristic thumping sound. This basic Aristotelian account of
biological function is likewise reflected in the first of Tinbergen’s four why-questions
pertaining to the ultimate or evolutionary explanations of adaptations, i.e. they contribute

to the ultimate success of the organism though survival and reproduction.

40

In 1973, Larry Wright developed a more refined theory of biological function,
which is well known to philosophers of biology.3 In his seminal paper “Functions,”
Wright argues that functions can be distinguished from other often-confused concepts
such as goals, indefinite versus definite functions (i.e. a function vs. the function),
accidental activity, and conscious fimctions (i.e. those imputed to an intelligent designer).
All of these other confounders, Wright argues, complicate what a function really is
because they hearken back to pre-Darwinian thinking. Wright distills his so-called
etiological definition of function thusly,

The function Of X is Z means:

(a) X is there because it does Z,

(b) Z is a consequence (or result) of X's being there.4
He goes on to illustrate how his account of function Offers an explanation about not just
what a function is based on its etiology, but also what it is about functions that is
teleological. He states:
The first part, (a), displays the etiological form of functional ascription-
explanations, and the second part, (b), describes the convolution which
distinguishes functional etiologies from the rest. It provides an etiological
rationale for the functional "in order to," just as recent discussions have
for other teleological concepts.5
Wright's etiological account of function stands in contrast to Cummins’s theory of
function, which locates the essence of function in the identification of causal
contributions to complex physiological processes.6 Cummins argued that function should

be assessed without an appeal to the origin of the particular part, but rather through an

41

analysis of that part’s role or capacity within a particular system. Cummins summarizes
this position in the conclusion to his 1975 article “Functional Analysis”:

To ascribe a firnction to something is to ascribe a capacity to it, which is

singled out by its role in an analysis of some capacity of a containing

system. When a capacity Of a containing system is appropriately
explained by analyzing it into a number of other capacities whose
programmed exercise yields a manifestation of the analyzed capacity, the
analyzed capacities emerge as functions.7
Thus, we can understand the function of the heart to be to pump blood not because of its
presence and etiology, but its contribution to the larger circulatory system.

But both Wright's and Cummins’s accounts of fimction suffer from
complementary flaws. First, Wright’s theory seems to be too restricted in that it captures
only a very specific kind of functional adaptation produced by natural selection. A classic
counterexample is that of feathers in birds. It is thought that feathers were originally
selected for their utility in maintaining homoeothermic balance, but then were later co-
opted for use in flight. Thus, as Kitcher explains, etiological explanations of function
must be disambiguated to account for the fimction of a feature in the here-and-now versus
what was ostensibly its original functional contribution.8

In Cummins’s theory, we see a reciprocal kind of problem. His theory seems to be
too loose because it encompasses too many instances of stochastic events as “causes” that
might be interpreted in some way as being functional. The counterexample to
Cummins’s model is portrayed by the example in which there is an arrangement of rocks

in a stream, which causes a particular flow of water that results in a widening of the

42

stream miles away. On Cummins’s account, because of their contribution to the system of
the stream, the widening of the stream should be considered the firnction of those rocks.
This of course seems preposterous, since there is no basis for determining that those
rocks are there for the purpose of stream-widening. Therefore, the recognition of some
token’s contribution or capacity to contribute to some feature of a larger system is simply
not sufficient for labeling it a function.9

Boorse offers his own theory of function to ground his BST, which is largely
based on a previous theory of function of by Sommerhoff as well his objections to both
Wright’s and Cummins’s models. Quite simply, Boorse returns to an Aristotelian notion
of biological function, stating that function,

...in the biologist's sense is nothing but a standard causal contribution to a

goal actually pursued by the organism. Organisms are vast assemblages of

systems and subsystems which, in most members of a species, work

together harmoniously in such a way as to achieve a hierarchy of goals.

Cells are goal-directed toward metabolism, elimination, and mitosis; the

heart is goal-directed toward supplying the rest of the body with blood;

and the whole organism is goal-directed both to particular activities like

eating and moving around and to higher-level goals such as survival and

reproduction. The specifically physiological functions of any component

are, I think, its species-typical contributions to the apical goals of survival
. to
and reproduction.

And in another paper, Boorse clarifies this definition by reminding opponents that

his theory is not altogether novel, but is rather the same classical understanding of

43

nonpurposeful teleology that had been recently refined by contemporary
philosophers of biology and cybemetics: H

In my view the basic notion of a function is of a contribution to a goal.’

Organisms are goal-directed in a sense that Sommerhoff, Braithwaite, and

Nagel have tried to characterize: that is, they are disposed to adjust their

behavior to environmental change in ways appropriate to a constant result,

the goal. In fact, the structure of organisms shows a means-end hierarchy

with goal-directedness at every level.12
Boorse stipulates that, although there will be various goals depending on level of
selection (gene, cell, organ, etc.), the basic notion of function will work in each and every
one of these contexts. NO matter the specialization of the biologist, each should be able to
see function in this fundamentally value-free way. For discussions of health, disease, and
illness, Boorse argues that it is the physiological notion of function that should remain
central to our analysis:

Most behavior of organisms contributes simultaneously to individual

survival, individual reproductive competence, survival of the species,

survival of the genes, ecological equilibrium, and so forth. As a result, it

appears that different subfields of biology (e.g., genetics and ecology) may

use different goals as the focus of their function statements. But it is only

the subfield of physiology whose functions seem relevant to health...This

assumption has definite consequences for our health concept and should

therefore be kept in mind. Whatever goals are chosen, function statements

44

will be value-free, since what makes a causal contribution to a biological

goal is certainly an empirical matter. ‘3

Boorse stipulates his definition of “normal function of a part or process within members

of the reference class is statistically typical contribution by it to their individual survival

and reproduction.”14 Thus, the reference class is defined as an ideal individual member

of the species. This ‘ideal’ is not a normative or ethical ideal but rather an ideal in the
Platonic sense. It is a reflection of the ideal form of the species that can be envisioned
through statistical analysis of a large sampling of particular traits of individuals within a
species. This is the form that we so often find in the images or diagrams of anatomy or
physiology texts.

Several objections have been raised against Boorse’s concept of function. One
well-developed and persistent objection comes by way of K.W.M. F ulford who claims
that Boorse’s concept of function is covertly normative. F ulford develops this objection
first by highlighting Boorse’s use of what he calls ‘evaluative’ terminology in discussing
instances of dysfunction and disease. F ulford essentially argues that the term .
‘dysfunction’ cannot be employed descriptively——— particularly in the context of
medicine—~— without it betraying a value judgment about that which is deemed
dysfunctional.” Invoking Austin, F ulford claims that Boorse’s word choice and his
examples expose this normativity. He states,

The key methodological insight of linguistic-analytic philosophy, as

described most explicitly by the Oxford philosopher, J.L. Austin, is that

the words we use may act as a kind of analytical probe to, or microscope

on, meanings...Hence our use of such concepts, i.e. the words we use for

45

real, may be a surer guide to their meanings than attempts to define them.
Hence Boorse’s use of “disease” with evaluative connotations may signal

that, his value-free definition of disease notwithstanding, there is an

essential evaluative element in the meaning of the term. '6

Without delving too deeply into the particulars of the philosophy of language here,

F ulford seems to be on to something about the difficulty of abstracting a concept like
biological function away from its medical context (at least in nosological theories)
without keeping the residue of certain evaluative elements created by the original context
Because of linguistic difficulty, Fulford thinks Boorse (as with other naturalists) is guilty
of making a sort of equivocation, “through inconsistency, through his repeated slips from
value-free definition to value-laden use of the concept.”17 One way to disentangle, or at
least make transparent, this confusion is to distinguish between the “doing” aspects of
function. In these cases dysfunctional “doing” applies to parts of organisms, while the

problems of “ordinary doing” reflect illness. It is in the conflation of what’s doing what

that causes confirsion. '8

F ulford’s second objection is related to his first and aims at the heart of Boorse’s
concept of function by taking issue with the broader attempt by philosophers of biology
to disentangle function and teleology in a meaningful way. Fulford claims that any

account of fimction that takes teleology seriously must in some way be evaluative. He

argues that,
...[this] point is an extension of that made above against naturalism on

disease.” The concept of a “goal”, being a teleological concept, does allow

us to speak of good and bad functioning by reference to whether or not the

46

goal in question is attained. But this is because goal itself, to the extent
that it is a teleological concept, carries an evaluative element of meaning.
A goal is not, merely, something which is hit or missed, as, say, a comet
merely hits or misses a planet: a goal is aimed at or targeted; it may...be

desired, needed, wished for, intended, etc; a goal is something which (in

itself) it is good to hit and bad to miss.”

Again, this objection makes sense when we consider the linguistic usage Of function
claims particularly within a medical context. F ulford’s objection appeals to the intuition
that goals must be considered valuable in some sense; without such value a goal is no
longer a goal. Such a ‘valueless’ goal would be nothing more than a random destination.
Indeed, most normativist critics of Boorse articulate this objection in some way or
another.

But for both of these objections, Boorse supplies reasonable and, in my opinion,
compelling rejoinders. First, Boorse answers Fulford’s linguistic attack by showing that
his use of words to describe states are not necessarily evaluative, and F ulford seems to be
excessively reading norms into Boorse’s statements. F ulford, as Boorse notes, offers an
oddly expansive list of ostensibly evaluative terms. To wit, Fulford even claims Boorse’s
use of the word ‘kidney’ is value-laden. Aside from pointing out the absurdity of this
claim, Boorse reminds us that his function concept relies on the “natural polarity” of
physiological processes, which, again, has been well-developed in the philosophy of
biology literature and based on classical theories. Reminding us that his concept Of
function is based on Sommerhoff’s more basic concept of value free functional goal

directedness (which drives an even deeper distinction between living and non-living

47

things) and Nagel’s systems approach to defining function, Boorse illuminates his
rejoinder:
The function of a physiological process is its contribution to physiological

goals. By ‘deficiency’ of fimction, then I mean simply less function, less

contribution to the goals, than average. This is an arithmetic, not an

evaluative, concept. An easy example is homeostatic functions like

regulation of body temperature or of blood pressure, gases, or electrolytes.

Insofar as what regulates these variables is directed to the physiologic goal

of constancy, deficient fimction is simply much greater variation, much

wider swings, than average, or failure to return from one at all.

Approaching from a slightly different flank, Engelhardt also attacks Boorse’s
concept of function. Among other things, Engelhardt claims that Boorse’s ‘fimction’ is
based on the survival of the species. This he claims is the wrong level of concern for
medical purposes because the goal of medicine is not the species but the well-being of the
individual patient. In other words, Engelhardt claims that Boorse gets the level of
selection for medical practitioners, as it is defined in terms of species typical function,
wrong. Moreover, Engelhardt claims that Boorse’s theory is normative because the
choice to prioritize species-typical over individual function is a value-based decision.
Boorse, who replies that Engelhardt is misinterpreting his theory, summarily discharges
this objection. Reiterating Somerhoff, Boorse claims that nothing about species selection
is normative—it simply is the case that a disease is best viewed by noting average

function and deviations therein. Species is simply the classification or category needed to

48

survey the landscape of averageness of individuals within that reference class. I will say a
bit more on this below.

One of the potentially stronger Objections to Boorse’s theory of dysfimction-as-
disease is the popular claim the Boorse conflates ‘difference’ with ‘dysfunction’. This
objection will be detailed more closely in the next section on mental illnesses because I
think it holds some merit in that context. However, in the context of somatic dysfunction,
I think Boorse would argue that his opponents should not misconstrue his definition of
dysfirnction as being synonymous with a folk definition of ‘difference.’ In fact, his
concept of function allows for an infinite array of differences. But it is those very
specific differences that undermine the ability of the organ or system or individual to
achieve their larger goals of survival and reproduction that are salient to Boorse. This is
to say, only consequential differences matter for Boorse. One reply would be that
Boorse’s logic belies a genetic fallacy in that we are judging function arbitrarily or
exclusively on the goals Of survival and reproduction and there might be other important
goals against which to judged function. This is a fair point—if we are willing to concede
naturalistic ground to normativists. The claim that survival and reproduction are the goals

that matter the most is a stipulation; however it is not arbitrary. It is one that serves as a

starting principle of evolutionary biology and thus naturalistic nosologies.

An allied and persistent objection posits that Boorse’s theory ignores evolutionary

biology because it idealizes uniformity across a species. According to this argument,
Boorse fails to recognize that variation and diversity are natural, and, moreover, drive
evolutionary change. Thus, by basing dysfunction on species typicality Boorse is

misguided because he idealizes species uniformity. This interpretation of Boorse

49

however is mistaken. Boorse clearly argued that his concept of function is not meant to
account for the epochs of evolutionary diversity and change. Rather, his use of the
concept of function is meant to explain disease at the immediate physiological level,
where species diversity is in fact quite narrow. Indeed, the establishment of a trait within
a species is marked by such uniformity. Otherwise, it would not really be a trait. As

Boorse states, “On all but evolutionary time scales, biological designs have a massive

constancy vigorously maintained by normalizing selection.”20

Nonetheless, despite Boorse’s clear replies, this set of objections has persisted in
the literature since the 19705. For example, Bolton has recently reiterated the claim about
difference-dysfimction conflation as one of the more devastating objections to Boorse’s
concept of fimction. This Objection, Bolton claims, is even more potent today because of
it has been amplified by those in the disabled community:

Whatever may have been the attraction of Boorse’s analysis several

decades ago, as a response to the 19605 controversies, it is particularly

problematic now in its proposal that mere statistical difference from some
population norm constitutes disease or some mental equivalent. It invites

the protest from individuals with such conditions—— now that they have a

voice— that difference is being pathologized and hence disqualified. 2]

Bolton’s confidence in this objection might be well-placed in a certain political sense, but
I think it misses the mark in refuting Boorse’s actual theory. Simply because Boorse’s
argument is now considered to be politically distasteful to some individuals does not, in

fact, make it theoretically unsound. Therefore, Bolton’s endorsement of this Objection is

nothing more than an instance of the bandwagon fallacy.

50

My point in presenting these thumbnails of objections to Boorse’s concept of
function is simply to provide enough background to claim that, while Boorse has been
subjected to withering criticism over the past four decades, his concept of biological
function stands up remarkably well to those attacks. Boorse’s core concept of species
typical function—at least when referring to physiological functions—~seems to be about
as objective as it gets when talking about any scientific concept. As Boorse himself
admits, of course, scientific concepts will be impregnated with a certain amount of
‘value’ brought to their investigation by the human investigator. Does this mean that
laws, theories or cOncepts like gravity, quantum mechanics or ideal gasses should be
under suspicion as nor'matively biased social constructions? And is the positivistic
standard impossibly high for concepts related to human health, disease, and illness?
Perhaps the level of “value-ladenness” found in the theories of particle physics or
chemistry instills less worry because theoretical constructions in the physical sciences not
only seem more “objective” in the positivistic sense, but also because these theories do
not have a direct impact on our daily life and welfare the way medical concepts might.

Ironically, however, while I think Boorse’s concept of function works well for
explaining the necessary and sufficient conditions of somatic diseases, I will argue it is
deficient for explaining those of a mental illness. I say this is ironic because mental
illness was actually a primary aim of Boorse’s theory when he first developed it. SO let

me now explain why I find his concepts of function and dysfunction to be too limited

when used to mark out what should count as a mental illness.

51

Dysfunction & Mental Illness
In the first of Boorse’s original quartet of papers where he describes his theory of
disease and illness, he assumes that there are “natural mental functions and also that
recognized types of psychopathology are unnatural interferences with these functions.”22
This assumption is then explained in his article, “What a Theory of Mental Health
Should Be.” Here Boorse explains that the mental functions can and should be defined in
the same way as biological functions. Mental processes can be understood as both
causally necessary to an individual’s actions, and contribute in some species typical way
to that individual’s overall fitness. Thus, there can be disturbances in these processes that
are dysfunctional and deviate from species typicality, which therefore count as mental
diseases. However, we should be clear here: Boorse is not a mere materialist on mental
disease and illness. He does not think that mental processes need always be tied to some
physiological correlate (though they might be). What he argues is that mental states need
not have identifiable correlative physical states. This would be analogous to when a
computer’s software is malfunctions; it would be a mistake to look only for a broken
piece of hardware to repair it. Likewise, although there might be a physical injury that
has caused a dysfunctional mental state, because a brain lesion is not apparent does not
rule out a mental malfunction. Mental states can themselves be the causes of mental
dysfunction by virtue of the fact that, for Boorse, normal and functional mental states
exist.
Boorse defines the normal mental state in terms of psychoanalytic theory

reinforced by contemporary physiological research. He argues that while it might be

impossible to identify the location of a mental state within the human mind, there is a

52

particular species-typical map of the mind that, although not yet anatomically defined,
can be assumed to be present as the origin and cause of mental states. Indeed, Boorse
recounts Freud who anticipated a reduction of psychoanalytic theory to its physiological
basis when in 1915 he said, “Our psychical topography has for the present nothing to do
with anatomy; it has reference not to anatomical localities, but to regions in the mental
apparatus, wherever they may be situated in the body.”23 Moreover, Boorse suggests
that Freudian psychoanalytic theory is analogous to a physiological model because the
substructures of the mind—the id, ego, and superego—are the basic systems of mental
activity. Speaking specifically of the those substructures, Boorse states that
...it is not entirely clear that the mental functions psychoanalysts describe
are functions in the biological sense. One sometimes has the impression
in psychoanalytic writing that the function of a mental process is the
gratification it can secure for the id. From the biological standpoint, the
function of a mental process is its contribution, not to our pleasure, but to
our behavior; pleasure itself has a function in producing behavior. But it
would not be difficult to construe psycholanalytic theory as a set of theses
about biological functions of the mind. On this view the id might emerge
as a reservoir Of motivation, the ego as an instrument of rational
integration and cognitive competence, and the superego as a device for
socialization.24 (italics mine)
Of course, Opponents who think this analogy is overly simplistic have attacked. For
example, Lavin has claimed that the psychoanalytic concept of flmction is different than

that of the physiologist, particularly because the substructures of the psyche “never fail”

53

in performing their requisite roles like physiological parts might. Boorse discharges this
claim by simply stating that they must be vulnerable to dysfunction since that is what
psychoanalysis treats?5 I think if we take this analogy more literally, a stronger objection
would be that it assumes the etiology of mental dysfunction to be ultimately
developmental. On the psychoanalytic account, the cause of most mental illnesses can be
located in a dysfunctional relationship with one’s parents, which somehow triggered a
maladaptive physiological response. This entails mental illnesses are not in fact
biologically based but, rather, they emerge from dysfunctional parent-child relationships.
In other words, by choosing psychoanalytic theory as his model of mental illness, Boorse
seems to undercut his own goal of locating mental illness within the sphere of biological
fimction.

Additionally, for Boorse to endorse psychoanalytic explanations as the most
feasible route toward a value-free concept of mental illness has always seemed strange to
me. Notwithstanding the fact that full-blown Freudian psychoanalysis has fallen into
disrepute in mainstream psychology, it seems undeniable that psychoanalytic theory is
deeply value-laden, because, for example, it idealizes particular parental and gender roles
and social dynamics as being healthy. The larger Objection that psychoanalysis simply
reflects or endorses particular moral values is crystallized by Joseph Margolis who posits
that the therapeutic role of the psychoanalyst is to routinely prescribe moral and ethical
kinds of “treatment” for their patients. Thus, work of the psychoanalyst is primarily

morally normative because their prescriptions are ultimately ethical decisions abOut what
constitutes the good (or less bad) life for that patient. 26 Without exploring the more

specific arguments about the scientific status of psychoanalysis, suffice it to say,

54

psychoanalysis is not considered to be a paragon of objective and positivist science.
While it might have scientific merit, I think it is reasonable to assert the methods of
traditional Freudian psychoanalysis do not pass the scientific test for falsifiability like
particle physics or biochemistry.27
To summarize, for Boorse, as with any other kind of dysfunction, mental
dysfunctions are diseases. He is critical of theorists and clinicians who think that mental
health is something “more grandiose” than this very basic definition of psychic
pathology. Because the substrata of the mind function in ways that should promote
individual fitness, those functions can be assessed according to the same criteria as
physiological functions. With this basic account of mental function explicated, Boorse
then goes on to explain when and how particular mental diseases should be considered
mental illnesses. He singles out the paradigm case of schizophrenia and explains why
personality disorders might be left out of his nosology:
Finally, the hope for contrasting responsible people with their mental
diseases grows vanishingly dim in the case of a character disorder, where
the unhealthy condition seems to be integrated into the conscious
personality...lf the term “mental illness” is to be applied at all, it should
probably be restricted to psychoses and disabling neuroses. . .It seems

doubtful that on any construal mental illness will ever be, in the mental-

health movement's famous phrase, “just like any other illness.”28

As we now see, the line for mental illness circumscribes only those instances of mental
activity or behavior that can be defined in terms of psychological dysfunction, which, in

turn, must be determinable by some objective, possibly physiological, measure. By now,

55

with all or our previous discussion about the aspirations of Boorse and the naturalists, this
. conclusion should not cOme as a surprise.
Let us now briefly turn to Jerome Wakefield’s theory of function. In much the
same way as Boorse, Wakefield claims that biological functions are completely value
neutral, while the degree to which these dysfunctions are harmful is a normative
judgment. Although Wakefield’s harmful dysfunction model of mental illness largely
parallels Boorse’s BST, a few important concepts should be reemphasized here. Indeed,
the limitations of Boorse’s function concept are even more clearly seen in Wakefield’s
harmful dysfunction theory particularly in the way Wakefield hopes to eventually explain
personality disorders. Resonating with Boorse, Wakefield describes function in a very
specific medical sense. He states, “Function and dysfunction in the medical sense refer, in
the first instance, not to the quality of a person’s performance in a given environment but
to whether mechanisms within the person are performing or failing to perform functions
they were designed to perform.”29 A dysfunction for Wakefield is defined as, “a scientific
term referring to the failure of a mental mechanism to perform a natural function for
which it was designed by evolution.” Wakefield thinks that cognitive mechanisms can be
assessed in terms of their evolutionary use and, in agreement with Boorse, can be
understood as analogous to physiological mechanisms:
Mental mechanisms like those involved in perception, motivation,
emotion, linguistic ability, and cognition play distinctive but coordinated
roles in overall mental functioning, much as different organs play
distinctive but coordinated roles in physical functioning. Thus, a

biological account based on evolutionary theory has seemed to many to be

56

potentially capable of handling the concepts of both mental and physical

disorder in a scientific and value-free manner. 30
For Wakefield, though they might be difficult to pinpoint, mental function and
dysfunction can be determined as purely value-free scientific assessments. It is
true that figuring out the ‘natural’ or frmctional mechanism of a mental process
can be incredibly difficult. Wakefield concedes this is far more difficult to
determine than a biological mechanism. He claims however that our ignorance
about what constitutes functional mental mechanisms should not deter us from
hypothesizing what we think mental mechanisms are fimctionally designed to do.
He states:
This ignorance is part of the reason for the high degree of confusion and
controversy concerning which conditions are really mental disorders.
Paradoxically, this ignorance about the detailed nature and causal histories
of mental mechanisms also makes it all the more necessary to rely on
functional explanations based on inferences about what mental
mechanisms are probably designed to do. In this respect, we are now at a
stage of understanding that is comparable in some ways to the position of
ancient physicians who had to rely on similar inferences in judging
physical disorder... As we learn more about the naturally selected

functions of mental mechanisms, our judgments about dysfunction will

become correspondingly more confident.“
Wakefield’s conjecture that we will more reliably determine the biological (or

evolutionary) bases for mental illnesses—including personality disorders—is

57

overly Optimistic because, as I argue in the next section, it is impossible to
determine the function of a personality in a value-free way.

Likewise, it turns out Boorse’s and Wakefield’s theory of dysfunction both fall
short in marking out all mental illnesses not because they are covertly normative or
internally flawed, but because they may actually be too successful in being value-free.
The critics of Boorse fail to see this possibility as a potential problem with his theory
because they are too preoccupied defending the (ideological) claim that all nosological
theories must, in one way or another, be normative constructions. They fail to consider
the possibility that, no, not all theories need be normatively infected and that,
alternatively, objective frameworks like Boorse’s may actually be flawed for other
reasons. It thus is plausible that Boorse’s theory is simply “too objective” to adequately
explain what should count as a mental illness. This is basically my position, and I will
now begin to illustrate my reasoning more carefully below. My pragmatic theory, as I
hope to show, emerges from the ramifications of this position vis—a-vis personality

disorders.

Biological versus Social Dysfunction: Schizophrenia & the Disordered Personality

To more fully distinguish between function concepts and core and boundary cases
of mental illness, let us now contrast, briefly, two kinds of mental illness: schizophrenia
and personality disorders. Schizophrenia should serve to illustrate how biological
dysfunction might be determinative of mental dysfunction. Thus, I will assume ’
schiZOphrenia exists and will set aside Szasz’s radical claim that schizophrenia is nothing

more than a social contrivance invented by medical authorities to underpin their ulterior

58

political motivations}2 For purposes of this discussion, we will keep the descriptions of
each disorder rather general. While it is true that schizophrenia is no longer considered a
unified mental illness but a continuum of schizotypical subcategories, for our purposes,
we’ll consider it to be a broad instance of mental illness. Likewise, personality disorders
are a diverse set of mental disorders. In chapters 6 and 7, I will more fully describe the
signs and symptoms of the borderline personality disorder as a detailed case study used to
illustrate my pragmatic theory of mental illness. For now, let us think about how the
concept of function is used to describe schizophrenia and personality disorders in general
terms.

Schizophrenia serves as a paradigm case of mental illness across most theories of
mental health and illness. The symptoms of schizophrenia include delusions,
hallucinations, disorganized speech and behavior; subtypes might include paranoia,
echolalia, catalepsy, etc. According to the ICM-IO, Schizophrenia, schizotypal and
delusional disorders are described across categories F —20 to F-29. Schizophrenic
disorders, at the most general level:

...are characterized in general by fundamental and characteristic

distortions of thinking and perception, and affects that are inappropriate or

blunted. Clear consciousness and intellectual capacity are usually
maintained although certain cognitive deficits may evolve in the course of

time. The most important psychopathological phenomena include thought

echo; thought insertion or withdrawal; thought broadcasting; delusional

perception and delusions of control; influence or passivity; hallucinatory

59

voices commenting or discussing the patient in the third person; thought

disorders and negative symptoms.33

Similarly, in the DSM-IV-TR the characteristic symptoms of schizophrenia are defined as
two (or more) of the following, each present for a significant portion of time during a 1—
month period (or less if successfully treated):

delusions

hallucinations

disorganized speech (e.g., frequent derailment or incoherence)

grossly disorganized or catatonic behavior
negative symptoms, i.e., affective flattening, alogia, or avolition

P‘P‘S‘Pt‘"

The range of schizophrenia disorders includes a number of more specific subtypes, which
are defined based on the variation and specific manifestations of the above
characteristics.34

For a naturalist, the first question about schizophrenia would be, “Are the
characteristic schizotypical behaviors instances of normal species functioning?” Boorse
answers this question by arguing first that in severe cases of schizophrenia we can clearly
an instance of biological dysfunction:

Some mental patients, e. g. catatonic schizophrenics, are clearly

incompetent with respect to these biological goals and would remain so

under almost any circumstances. Whatever the detailed functional

'organization of the human mind and body may be, then, these people

...depart fiom it and so are authentically unhealthy... 35

Why might we consider the catatonic or paranoid schiz0phrenic patient to be
dysfunctional and unhealthy? Boorse replies that psychoses are instances of internal

conflict between impulses or desires and reality, which, without a functional apparatus

60

for negotiating this conflict, degrade into disorder. Precisely because the particular
mental substructures and cognitions that allow the individual to live according to their
desires within the constraints of the real world are degraded in the psychotic patient, they
will fail to thrive.
By this standard schizophrenia and all other psychoses with thought
disorders look objectively unhealthy. Moreover, it one accepts the
traditional analytic description of the neurotic process, very limited
functional assumptions will suffice to construe serious neurosis as a
disease. Since opposite desires are common in human beings, there must
be some normal mechanism for resolving them without permanent and
paralyzing conflict. If some of the neurotic's strongest desires remain
locked in combat without freely releasing their motivational force in

behavior, it is not an implausible hypothesis that the conflict-resolution

mechanism is functioning incorrectly.36
Boorse claims that behaviors characteristic of psychotics suffice to show that such
behaviors are dysfunctional and are thus unhealthy. Further, they are illnesses by virtue
of the norms related to their desirability or social value, which for schizophrenia is
clearly undesirable in our society. Boorse states that he is confident that schizophrenia is
a dysfunction, and thinks, “Any stronger vindication of current clinical categories would
require a detailed and well-confirmed theory of the functions of a normal human mind.”37
Perhaps, by this, he means in part, some well-established empirical data about species
typical functioning of the brain. And in fact, as the growing body of empirical research

into schizophrenia illustrates, there are statistically significant differences in the anatomy

61

and physiology of the brains of schizophrenic individuals. It is, in fact, these data about
statistically normal brain form and firnction that bolster the naturalists’ theory of mental
illness in the case of schizophrenia.

However, I believe personality disorders to be fundamentally different, at least in
terms of how they are distinguished from normal personalities. Personality disorders are
defined in the DSM-IV—TR as “an enduring pattern of inner experience and behavior that
deviates markedly from the expectations of the individual's culture, is pervasive and
inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to
distress or impairment.” Thus, they are defined in terms of their cultural context and as
such, are not dependent on any concept of biological function. In contrast to
schizophrenia, lapses in socially determined standards of behavior are sufficient
conditions for ascribing the label of personality disorder. This is to say, they rely on a set
of cultural expectations about what is socially desirable and acceptable, which, in turn,
define personalities that are functional and dysfunctional. We see the appeal to cultural
norms as explicitly in the [CD-10 definition for the range of personality disorders (Block
F -60 to F -69), “specific personality disorders (F60.-), mixed and other personality
disorders (F61 .-), and enduring personality changes (F 62.-) are deeply ingrained and
enduring behavior patterns, manifesting as inflexible responses to a broad range of
personal and social situations. They represent extreme or significant deviations from the
way in which the average individual in a given culture perceives, thinks, feels and,
particularly, relates to others.”38

As I continue to develop the pragmatic theory, we will see that key markers of

personality disorders that make them candidates for mental disorders will be common

62

features such as the constellations of behavior (to be defined in terms of habits) that are
judged to be dysfunctional as well as the form of suffering they cause both to the patient
and others. For now, it is important to recall where we have been conceptually: from
naturalist arguments we see that biological function claims can be used to make
analogical arguments about social fimction and dysfunction. From there we can see that
particular kinds of social dysfunctions may be grounded in biological dysfimction. Such
is the case with core cases of mental illnesses like depression and schizophrenia.
However, other potential mental disorders lack this biological grounding at present, and
remain defined in terms of social dysfunction. In the chapters to come, I will develop my
argument that, in short, says that considering particular culturally defined dysfunctions as
if they are cases of naturalistically defined dysfunctions is a reasonable and defensible

pragmatic solution.

Conclusion

This chapter presented a broad overview of the concept of function as it relates
both to the biological sciences and medicine. As we saw, naturalists like Boorse rely on a
physiological-evolutionary concept of normal function to determine the healthy from the
diseased. This concept of biological function is used to discern what should count as a
somatic and mental disease. Although his thesis is now sometimes dismissed out of hand,
as I have argued, Boorse’s naturalistic nosology is remarkably coherent and continues to
stand up well to decades of philosophical criticism and, at times, rhetorical sniping. 39
However, it is a victim of its own success in that it is too limited in the way it handles
instances of psychological dysfunction- particularly in cases recognizable only by appeals

to social dysfunction. Indeed, it has been argued elsewhere that antisocial personality

63

disorder conflates two “universes of discourse: the universes of personal and social
deviance.”40 It will be my task to more clearly parse these universes and show why
considerations of social deviance might be ethically used to justify the continued
medicalization of personality disorders.

I have shown that social dysfunction is an equally important concept to include in
any nosology Of mental health. We see instances of how social dysfunction currently
characterizes the broad category of personality disorders. Now I must justify why this
should be the case and how pragmatic theories will prove helpful in providing a more
philosophically robust concept of mental illness. Therefore, my next task is to highlight
helpful theoretical starting points found in other pragmatic models of mental illness and

describe my own proposal, which I will do in the next chapter.

 

1. Since Wakefield’s theory is largely based on Boorse’s, I will collapse my discussion of function
found in both theories and deal only with Boorse’s.

2. Philip Kitcher, “Species,” Philosophy of Science 51, no. 2 (1984): 308-333.

3. Larry Wright, “Functions,” Philosophical Review 82, no. 2 (1973): 139—168.

4.1bid., I61.

5.1bid.,161-162.

6. Robert E. Cummins, "Functional Analysis," Journal of Philosophy 72, Nov. (1975): 741-764.

7. lbid., 765.

8. This is where Gould’s theory Of exaptations comes in, though 1 said I would not talk about it,
even though 1 seem to be now.

9. I should mention here that Philip Kitcher has attempted to synthesize these competing concepts
of function with talk of ‘design’, which he argues answers first the problem of evolutionary accidents that
Wright’s concept fails to address. Second, Kitcher’s use of design focuses on a part’s relevant capacities by
exposing the ‘source of design in the background’ of any causal story. Suffice it to say, Kitcher’s function
synthesis takes us far down the intellectual road in understanding species typical functioning for use in
naturalist and hybrid nosologies. (see It. 2)

10. Christopher Boorse, “On the Distinction Between Disease and Illness,” Philosophy and Public
Aflairs 5, no. 1 (l975):49-68.

11. Somerhoff’s and Nagel’s accounts are extensions of inquiries into function concepts dealing
with cybernetics in the 1950’s. They are intended to show that goal directedness can be internally regulated
by the animal or machine without purposefulness.

12. Christopher Boorse, “Health as a Theoretical Concept,” Philosophy of Science, 44, No. 4
(I977): 555

13.1bid., 556.

14. Christopher Boorse. “A Rebuttal on Health,” in What is Disease, ed. James M. Humber and
Robert F. Alrneder (Totowa, N.J.: Humana Press, 1997), 7.

64

 

15. K.W.M. F ulford, Moral Theory and Medical Practice (New York: Cambridge University
Press, 1989); K.W.M. Fulford, “What is (Mental) Disease?: An Open Letter to Christopher Boorse,”
Journal of Medical Ethics 27, no. 2 (2001): 80—85.

16. Fulford, 2001, 81.

17. lbid., 84.

18. Fulford, 1989, 127.

I9. lbid., 81.

20. Boorse, I977, 557.

21. Derek Bolton, What is Mental Disorder? An Essay in Philosophy. Science, and Values (New
York: Oxford University Press, 2008), 115.

22. Boorse. 1975, 63.

23. As cited by Christopher Boorse, “What a Theory of Mental Health Should Be,” Journal for
the Theory of Social Behavior 6, no. 1 (1976): 65

24. Boorse, I976, 78.

25. In Boorse, Rebuttal. (see n. 14)

26. Joseph Margolis, Psychotherapy & Morality (New York: Random House, 1966); Boorse,

1975, attacks this thesis stating: “Margolis argues in his first chapter that psychoanalysts have been
mistaken in holding that their therapeutic activities can 'escape moral scrutiny.’ From this he concludes that
’it is reasonable to view therapeutic values as forming part of a larger system of moral values,’ and
explicitly endorses normativism. But this inference is a non sequitur. From the fact that the promotion of
health is open to moral review, it in no way follows that health judgments are value judgments.” (54)

27. Karl Popper. Conjectures and Refutations: The Growth of Scientific Knowledge (New York:
Routledge, 2003); Popper’s view of F reud’s theory is not without controversy. See: Adolf Griinbaum, The
Foundations of Psychoanalysis: A Philosophical Critique. (Berkeley, CA: University of California Press,
1984) and Adolf Grilnbaum, “Is Psychoanalysis a Pseudo-science? Karl Popper versus Sigmund Freud,”
Zeitschriftfiir philosophische Forschung, 31, H3 (1977): 333-353; Grunbaum’s argument is that Freud‘s
theory is falsifiable and ultimately Popper's method for distingutishing between science and pseudoscience
is flawed.

28. Boorse, 1975, 66.

29. Jerome C. Wakefield, “Aristotle a Sociobiologist: The ‘Function of a Human Being’
Argument, Black Box Essentialism, and the Concept of Mental Disorder,” Philos0phy, Psychiatry, &
Psychology 7, no. I (2000): 20

30. Wakefield, 1992, 378. (see ch.1. n. 32)

31.1bid.,383.

32. In his book Schizophrenia: The Sacred Symbol of Psychiatry (Syracuse, NY: Syracuse
University Press, 1976), Szasz states his thesis thusly, “What is schizophrenia?...The point I wish to
emphasize here, right at that the outset, is that the claim that some people have a disease called
schizophrenia was based not on any medical discovery but only on medical authority; that it was, in other
words, the result not of empirical or scientific work, but of ethical and political decision making.”(3). In a
recent interview with Australian Broadcasting Corporation (April, 4 2009), when asked about the reality of
the symptoms of auditory hallucinations of schiZOphrenia, Szasz responded that all talk of schizophrenic
symptoms question—beg and that auditory hallucinations are nothing more than self-talk: “Well it‘s
impossible to answer this kind of question because it is based on a story which already validates psychiatry.
Now where is this man who is rocking back and forth in his own urine? I've never seen such a person in
more than 50 years of psychiatry—where is he, how did he get there, who is he and how does a psychiatrist
know that he is talking to the CIA? There is only one way he could know that, that's by the patient telling
him and the patient tells you that the CIA is talking to him; let's assume if someone told me that I would tell
him, well congratulations, you are a very important person. That’s not against the law.” (Accessed
November 2009: http://wwwabc.nct.au/m/allinthemind/storiesf2009/2530830htm )

33. World Health Organization, The [CD-10 Classification of Mental and Behavioural Disorders:
Diagnostic Criteria for Research. (Geneva: WHO, 1993).

34. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders 4th
ed., text rev. (Washington, DC: American Psychiatric Association, 2000).

3S. Boorse, 1976, 77.

36. lbid., 77.

65

 

37. Ibid, 77.
38. World Health Organization. lCD-lO (2007)
http://appswho.int/classifications/zmps/icdticd l Oonlinc/“index.htm‘gthhtm+F640 (accessed May 12,

2010)
39. George J. Agich, “Evaluative Judgment and Personality Disorder” in Philosophical
Perspectives on Psychiatric Diagnostic C lassi/ication, ed. John Z. Sadler, Michael A. Schwartz, and
Osborne P. Wiggins (Baltimore, MD: Johns Hopkins University Press, 1994), 233-245.

40. lbid., 242.

66

CHAPTER 3

THE PRAGMATICS OF MENTAL DISORDER: A THEORETICAL SYNTHESIS

Introduction

In the previous two chapters, I sketched out the landscape of philosophical
theories of health and disease and the central concept of function. As I have shown, the
core cases of mental illness and disorder can be reasonably described in terms of both
biological and social dysfunction. Further, Boorsian naturalism, notwithstanding its now
well-known drawbacks, takes us surprisingly far in our description of core cases. Thus, it
seems reasonable to claim -— and recent data bear this out-——— that a core case such as

schizophrenia represents an empirically measurable deviation in the statistically normal

development, structure and function of the human brain.1 Though there is still
considerable controversy surrounding this point, the literature I have surveyed points to a
growing consensus about the fact that schizophrenia is marked by brain lesions or
developmental abnormalities, which satisfy the functional criteria of a disease, at least
according to mainstream naturalists. Likewise, with depression and bipolar disorder
there are substantial data to support the claim that these are instances of biological
dysfunction in Boorse’s sense. Thus, we can at least grant Boorsian naturalism some
degree of explanatory credit for the conceptual foundations of core cases.

In contrast, personality disorders qua boundary cases— those kinds of mental
illnesses that are currently defined either primarily or exclusively in terms of social
dysfunction—- remain stubbomly resistant to categorization according to naturalistic
theories. As we have seen, Boorse does attempt to correlate character disorders to

dysfunctions of Freudian mental apparatuses. I think it is safe to discount this approach

67

as being, at best, not falsifiable and, at worst, theoretically incredible. Nonetheless, it
should be noted that more sophisticated research into the biological bases of personality
disorders is afoot. Researchers are currently working to identify neurochemical
substrates, morphological characteristics of the brain, and the genetics of personality
disorders. For example, researchers have used fiinctional MRI and positron emission
tomography to examine the brains of individuals with borderline personality disorder
noting differences in metabolism and structure in parts of the prefrontal lobe and limbic
system.2
As we examine the empirical data, we must remember: all of these studies

presuppose a pre-neurological set of criteria about normalcy and personality types, upon
which researchers depend before they can even begin the task of identifying correlates.
And despite the push for a scientifically based categorization of personality disorders, the
key feature of all personality disorders, according to the DSM, remains the “enduring

pattern of inner experience and behavior that deviates markedly from the expectations of
the culture of the individual who exhibits it.”3 As we know, this culturally bounded
definition is similarly reflected in the WHO’S definition of personality disorders as,

“representing extreme or significant deviations from the way in which the average

individual in a given culture perceives, thinks, feels and, particularly, relates to others.”4

Thus, both diagnostic schedules recognize that personality disorders are culturally
determined and that biological evidence is not, should not, and cannot be determinative
of their etiology. It is thus an odd feature of both the DSM and 1CD that they aspire to
evidence-based categories but simultaneously cling to socially determined ones in the

case of personality disorder.

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As one might expect, in spite of the hopes of the APA to define personality
disorders in both scientific and culturally dependent terms, there exist mainstream
theories of personality within psychology and psychiatry that explicitly hold that
personality disorders are not diseases at all. For example, Theodore Millon, whose
substantial work in personality theory cannot be understated, holds the position that
personality disorders are not diseases despite the tendency to define them as such. In his

well-known text, Personality Disorders in Modern Life, Millon and Davis state,
By presenting the personality disorders as entities that can be diagnosed,
the DSM encourages the view that they are discrete medical diseases.
They are not. The causal assumptions underlying Axis I and Axis II are
simply different. Personality is the patterning of characteristics across the
entire matrix of the person. Rather than being limited to a single trait,
personality instead regards the total configuration of the person’s

characteristics: interpersonal, cognitive, psychodynamic, and biological.

For the personality disorders, then causality is literally everywhere.

Millon’s own approach aims to capture the interplay between biological, social, and
cultural forces that may instantiate as disordered personalities. His theoretical approach
holds promise because it is, in a sense, pragmatically oriented in its recognition of the

emergent properties of personalities, its rejection of the reductionist tendency to try to
define personality disorders as biological dysfunctions (diseases), and it avoids the
obvious pitfalls of Boorsian naturalism based on antiquated Freudian mechanisms.

However, Millon himself provides an unabashed naturalistic explanation in his

construction of an evolutionary theory of personality. He argues that the healthy

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personality is the one that fits with the universal (natural) goals of survival, reproduction,
“happiness, avoidance of pain, and adaptation. Thus, while he would reject the claim that
personality disorders are reducible to biological functions, he proposes an equally
nonnorrnative account of how personality disorders should be described. Without
spending pages detailing Millon’s model, suffice it to say his theory reflects the same
aspirations of a naturalist such as Boorse: “The evolutionary model believes that
evolution is the logical choice as a foundation for an integrated science of the person.”
For Millon, a functional personality is part-and-parcel of what is evolutionarily
advantageous. It allows for important social bonds to be formed and for the entire
individual to successfully navigate complex social structures and interpersonal
relationships. Moreover, a functional personality supplies the necessary skills to
negotiate intrapersonal and interpersonal conflict thereby allowing the individual to
eventually reproduce or advance their own fitness in some other way.

What this shows is that Millon’s seemingly promising theoretical alternative to
Boorsian naturalism is actually another blind alley; it returns us to the original problems
that render naturalistic explanations of personality disorders insufficient. This is to say, it

provides an account for the core cases of mental dysfunction but stops short of providing
a truly robust account of what makes a particular personality naturally functional or
dysfunctional. The debate about the infiltration of norms would surely ensue and we’d

find ourselves back at square one.

At this point, to reiterate, we have a strategic choice to make as we figure out a

better theoretical underpinning for boundary cases: (1) We can accept naturalistic

theories of mental illness and wait for empirical evidence to justify our nosology of

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personality disorders. This is option is taken by clinically trained scholars of philosophy
of psychology and psychiatry such as Jerome Wakefield; (2) We might jettison
naturalism altogether and search for a better and more widely encompassing theory—~—
perhaps one that wholeheartedly embraces the idea that mental disorders are social
constructions; (3) We could ignore boundary cases altogether as nonmedical social
problems that fall outside the domain of medicine; or (4) We could expand the scope of
our theory of mental disorder to include psychological-medical interventions for
boundary cases as a matter of practical importance, irrespective of whether they are
‘natural kinds’ or ‘diseases’. Again, lam taking the fourth tack. And as a reminder, in
drawing the boundaries between clearer cases of mental disease and boundary cases
psychological disorder exemplified by personality disorders, 1 wish to remain more-or-
less agnostic about the ontological status of personality disorders. That is, the question of
whether personality disorders are in actuality ontologically related to other mental
illnesses such as schizophrenia will be considered less important than showing why we
should treat them as if they are ontologically related.

Let us now examine two pragmatic theories of disease and mental illness offered
by philosophers George Agich and John Banja. We will see that the move toward a more
atheoretic pragmatism in psychiatric nosology is a laudable first step and is already
implicit in the DSM. However, current pragmatic theories of mental illness seem to
founder in two respects: (1) They do not offer a clear enough justification for
distinguishing between mental illness and vice and (2) They do not provide guidance for

the transparent and ethical application of the theory when categorizing constellations

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behaviors. These will be the two theoretical lacunae I will attempt to fill in with my

theory in the following chapters.

Agich ’s Pragmatic Theory of Mental Illness

Over the past 20 year, philosopher George Agich has developed one of the most
developed pragmatic theories of health, disease, and illness. As mentioned above, Agich
has argued that the DSM itself presents evidence of the practical and evaluative
dimensions of psychiatric nosologies. Although he has been very critical of Boorse’s
naturalism, his concern isn’t so much to refute Boorse’s theory but rather to show that
whatever the true nature of mental disease might be, the practical importance of
categorization supersedes concerns about metaphysics. In his analysis of the diagnostic
criteria of anti-social personality disorder (APD), Agich has crystallized his views thusly,

...my analysis does not commit me either to a rejection of psychiatric

diagnosis as myth or political critique of the clinical use of the diagnosis

APD. However, I do share with critics of psychiatric diagnosis and AFB a

belief that psychiatric diagnosis is essentially a matter of practical ethics;

unlike them I accept the descriptive aspect of diagnosis and believe that

nosology is an eminently practical and pragmatic exercise. My

hypothesized pragmatic view of contemporary classification of psychiatric

disease reinforces this point.7
This statement dovetails with my own intuition that the ontological status of mental
disorders provides little guidance in our construction of a psychiatric nosology that meets
practical and ethical muster. This is a claim 1 will develop in chapter 5. But now we must

ask: What is it that Agich’s “hypothesized pragmatic view” actually offers?

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Agich first recognizes and reviews the theoretical split between naturalistic
theories and theories about the sociopolitical constructions of disease. He believes both of
these models of disease are unsatisfactory for understanding the nature of disease and
especially the mental illness. He is, of course, more sympathetic with the normative
theorists. In his 1997 critique of Boorse, Agich defends his own pragmatic theory of
disease by deploying four specific arguments to show that disease is better understood in

pragmatic terms that are not committed to ontological claims about species typicality or

biological function.8 His overall position turns on the basic claim that the use of the term
‘disease’ in ordinary language and the practice of medicine reveals that it is a pragmatic
construct. The foundations of this position are fully articulated in Agich’s 1983 paper,
“Disease and Value: A Rejection of the Value-Neutrality Thesis.” 9 It should be noted
that, in his 1997 paper at least, Agich restricts his argument to assert only that disease
might be considered to be a practical concept; he stops short of saying that disease ought

to be considered a practical concept though he does endorse the cultivation of a more

pragmatic view elsewhere.10 I will develop this normative claim later. Let us now look at
his set of arguments in more detail and consider them as a springboard for my project.
Agich’s first argument about the pragmatic dimensions of the concept of disease
is essentially mined from the philosophy of language combined (implicitly) with Talcott
Parsons’s well-known concept of the sick role. Agich states that the language of disease
emerges from the very basic social need to address instances of human suffering and to
assign particular roles and characteristics to mark out those people who suffer in
particular ways. Thus, ‘illnesses’ are subjective feelings and are grounded on something

more basic-—a ‘disease’-——which makes possible a discourse about common features of

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instances of individual suffering. This is important because, as Agich states, channeling
Parsons, “to be sick involves implicit claims about oneself as well as claims made by
others about oneself. . .the sick individual is relieved of some responsibilities. We allow,
for example, sick leave and commonly accept sickness as an excusing condition for poor
performance, because we recognize that sickness befalls individuals and diminishes or
distorts their capacity for autonomous action, thought, and feeling.” Moreover, it is
assumed that the sick individual should want to get better and is expected to seek out and
cooperate with a health care provider. The upshot, according to Agich, is that the sick

role can only be filled by those people who are truly sick, and to be truly sick means one
has a disease.

Thus, the concept of disease is simply a practical measure against which society
more generally and health care providers specifically validate that a person is truly sick.
In other words, disease is a tool that serves the practical purpose of categorizing people
who should receive medical attention versus those who might need some other form of
support (or none at all). In responding to Boorse, Agich further claims that, “the goal of
scientifically explaining disease in terms of causal laws is thus not a free floating
intention, but is ultimately grounded in a historically mediated response to the universal
human experience of illness and sickness.” H This argument complements and reiterates
Engelhardt’s brand of strong normativism, by pointing to the intrinsic evaluative
elements within the language of medicine.12

Agich’s next broad claim is that even the most objectively oriented or “science-
based” theories of disease, illness, and health are permeated with values. Indeed, even

granting the possibility that Boorse’s theory of disease seems nonnormative, Agich notes

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that nothing comes of that theory—~in practice—until values are brought to bear on the
disease transforming it into an illness. Agich notes that Wakefield rightly sees the
integral part played by values in his harrnful-dysfunction theory of disorder. But on both
counts, Agich argues that disease and function claims are contaminated with values. In
agreement with Fulford, Agich thinks that the so-called “science-based” descriptive
claims of function are actually commingled with evaluative language and are
camouflaged in our ordinary language as objective terminology. He states that,
Some value terms can have predominantly descriptive connotations in
contexts in which the descriptive criteria for the value judgments that they
express are largely settled or agreed on. Where convention or social
agreement exists, value terms can be accepted as descriptions, but

whenever disagreement occurs, the descriptive content tends to fall away

and we are left with disputed evaluative content. 13

To illustrate this point, Agich, citing Fulford, offers the example of physical pain, which
is generally considered an ‘evil’ that most people avoid. Of course, there are individuals
who seek out physical pain because they find it pleasurable. However, these people are, it
seems, few and far between in relation to those who wish to avoid physical pain. In
contrast, there is less of a consensus about the nature and desirability of particular mental
‘pains’ such as anxiety or melancholy. Thus, Agich believes that since many people seek
out anxiety-inducing situations for the “thrill of fear” it is no wonder that “mental illness

in which anxiety plays an important part will appear to be more value laden and hence

. . . . ,, r4 . . . . ,
more controversral than physrcal illnesses caused by pain. Hrs pornt, quite Simply, IS

75

that the terms we consider to be reflections of natural kinds are simply the ones to which
we are accustomed.

Agich continues by arguing that a pragmatic theory of disease has several
advantages over other kinds of theories. He claims first that understanding disease in

practical terms “encourages a historically and socially situated analysis of the

construction and use of disease concepts.” 15 For Agich, the key advantage of the
pragmatic model is that it is “self-critical”, meaning that pragmatists for disease are
forced to grapple with the specific contexts of the concepts they espouse. In the case of
mental illness, they must offer justifications for their use of disease and illness terms in
each instance in question, thereby making explicit the values that might be brought to
bear on a particular set of behaviors. The touchstones of a philosophically coherent
pragmatic theory of disease will account for the main purposes of the concept of disease:
to care, cure, control and communicate. Without delving into Agich’s explanation of each
dimension, suffice it to say in each case a pragmatic theory of disease allows for a clearly
articulated justification or enhanced ability to achieve these goals.

Indeed, as Agich has argued, the current and previous editions of the DSM have
been implicitly pragmatic in the way they grapple with these goals. This should not come
as a surprise to those who know a bit of the political history of the DSMs such as the
now-infamous controversy about homosexuality.16 Agich claims (in relation to the third
edition) the DSM presents a series of contrary tendencies—to be both scientifically
“objective” while also accommodating a clear need to categorize particular disorders that
are only socially and contextually defined. He points out that the DSM-Ill promised to

describe mental illness in terms of “behavioral, psychological, and biological

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dysfunction” and that the multiaxial framework, which premiered in that edition, offered
a biopsychosocial framework for characterizing mental illnesses.
In their analysis of the process of developing diagnostic frameworks, Sadler,
Hulgus, and Agich mount a vigorous challenge to Robert Spitzer’s defense of the DSM’s
scientific validity. They did this initially in a 1994 paper, wherein, among other things
they argue that under Spitzer’s lead, the DSM working groups had not properly
acknowledged the values and pragmatic bargains being made during the development
process.17 They argue that the DSM working groups do often offer a set of validated
methods for assessing mental disorders but that these methods are often compromised or
substituted for more practical models of diagnosis. As a case in point, they argue that the
dimensional model of diagnosis—which tracks the clinician’s estimate of severity——and
the categorical method of diagnosis are nothing more than pragmatic artifacts. They say:
Another example of conflict between values of scientific rigor and
practical (clinical) utility is the DSM—IV era considerations of dimensional

versus categorical personality diagnosis (PD). It is significant that

someone as resolutely “pro” DSM as Thomas Widiger recognizes that the

formulations of personality and

science supporting dimensional

personality disorders is stronger than the science supporting the
categorical diagnosis for PDs. A practical consideration for PD diagnosis
is that clinicians don’t find personality dimensions a familiar and useful

way of conceptualizing patients. This conflict between scientific values

and practical ones was evident in DSM-IV deliberations.

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Similarly, the DSM-Ill stipulated “there is no assumption that each mental disorder is a
discrete entity with sharp boundaries between it and other mental disorders, or between it

and no mental disorder.”19 Yet, the differential diagnosis method parses manifestations

of potential mental illness by first filtering them through biological criteria. The larger
structure of the DSM prioritizes those categories that can be grounded on specific organic
causes and diagnosis should begin with consideration of conditions with established
biological bases. For example, for patients with both schizophrenia and dysthymia,
schizophrenia should be diagnosed as the primary diagnosis. Despite this prioritization in
diagnosis, as Sadler, Hulgus, and Agich have pointed out with regard to the DSM-III, the
development of a more robust genetic nosology of schizophrenia might have been
developed but was traded-off for more traditional, clinically useful, and less scientifically
valid models for diagnosis.20 Likewise, Sadler, Hulgus, and Agich challenge Spitzer’s
reasoning for the elimination of terms like ‘neurosis’ and his willingness to forego

compatibility with the ICD as instances of practical considerations overrode scientifically

based ones}!

In his 2001 response to their 1994 paper, Spitzer rejects the claims of Sadler, et al.
arguing that their interpretation of the development process of the DSM has been
misguided. Spitzer acknowledges that the development of the DSM is a deeply value-
laden and political enterprise. He should know: it was under his leadership that
homosexuality was redacted from the DSM. However, Spitzer claims, the DSM task
force members were under no impression that they were working in a ‘value free’ way.
According to Spitzer, the claim made by Sadler, et al. that the DSM was naive about the

values being used to make classification decisions was simply false. Moreover, Sadler, et

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al. misunderstand the meaning of psychological validity—in the context of the DSM,
validation is meant as a means to back up the overall description of the disorder category.
Validation information may include, “etiology, risk factors, usual course of the illness,
whether it is more common among family members, and most important, whether it helps
in decisions about management and treatment.”22 Sadler, et al. also misunderstand how
validation and reliability are related. They argue in the DSM there was a conflict between
these concepts. But according to Spitzer, the goals of both validation and reliability are
not in conflict, but rather complementary, with reliability adding an additional
undergirding to a valid mental disorder. Spitzer says, “Although a diagnosis can be

reliable but have no validity, unreliability provides an upper limit to the validity of a

. . ,,23
dragnosrs.

Spitzer responds to several other points of contention related to the pragmatics of
the DSM, concluding that really, in the end, the most significant source of conflict was
not in values arguments about particular diagnoses, but rather the conflict within the field
itself. For example, psychodynamic practitioners felt as though their particular
approaches and methods were threatened and devalued by the new DSM. Ultimately
however, for Spitzer, there was no doubt that values had infiltrated the classification
process—~it would have been silly to think they would not. Moreover, there was a robust
literature that examined and explained these values and tradeoffs throughout the revision
process.

Nonetheless, we can revisit similar questions about the DSM-V raised by Sadler,
et al. Are these same pragmatic assumptions and trade-offs Operational in the current

development of the DSM-V? Such a question is even more pressing because the task

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force leading the creation of the next edition promises to expand the “scientific basis for
psychiatric diagnosis and classification.”24 This will entail marshalling evidence from
genetics, molecular biology, and neuroscience and using those data as touchstones fora
new set of diagnostic categories. It would seem that pragmatic tradeoffs that riddled the
DSM-III process would be less likely to occur or, at the very least, be discouraged.
Regardless, a continued appeal to practical criteria shapes the definitions of personality
disorders, which can be seen in the preview of the DSM—V. The current proposals state
that personality disorders will be defined as variances within the larger personality
“domain,” which will be defined according to five dimensions:

1) an overall rating of personality (self and interpersonal) functioning

ranging from normal to severely impaired

2) prototype descriptions of major personality (disorder) types

3) personality trait assessment, on which the prototypes are based, but

which can also be used to describe major personality characteristics of

patients who either do not have a personality disorder or have a

personality disorder that does not conform to one of the prototypes

4) generic criteria for personality disorder consisting of severe deficits in

self differentiation and integration and in the capacity for interpersonal

relatedness

5) measures of adaptive functioning.
Taking special note of dimensions 2 and 3, we see a prototype analysis, which,'as will be
discussed below, is a method of grouping that relies upon the sampler’s experience with

many similar cases. Moreover, the new categories will be established based on the goal

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of providing clinical treatment—~a goal that begs the central questions of what it is that
should be or is being treated.

We might also acknowledge Spitzer’s very reasonable rejoinders but also argue
that to the extent there are conflicting messages within the manual itself, and in the
process related to developing new categories of personality disorders, the use of a
pragmatic methodology is generally ad hoc. A well-developed pragmatic theory of
mental illness should have the resources to deal with this problem in a systematic way.
For example, Agich’s theory demands a level of self-reflectiveness that is continually
critical of the products of its classification. This is to say that Agich’s main focus is on
offering a theory that allows for analytic honesty among those engaged in the
classification effort—such as those on the APA DSM working groups———about their
possibly unspoken goals and the consequences of their taxonomies. Likewise, Sadler, et
al. argue that a more explicit recognition of values in the DSM will lead to an
understanding that “value choices, conflicts, and commitments have had a significant,
indeed essential, role in the shaping the DSM. . .explicit attention to. ..values in DSM will
contribute to a more self-reflective, fair-minded, and responsive nosological
process. . .values have been broadly involved in the nosological choices reflected in the

DSMs, and their analysis and discussion should become a central part of future DSM
processes.” 25 This call for nosological value-transparency is a crucial point to keep in

mind as we move forward.
Some might argue that the process of developing the new DSM is proceeding in. a

way that is open to public and professional comment and is transparent. This claim is

true to an extent. The DSM—V working groups have posted all of their deliberations,

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research, and proposals to a publically accessible website. Likewise, there is a
mechanism in place for public and professional feedback on all proposals developed by
each work group. However helpful these commenting tools might be, A gich suggests
that a deeper examination of value-based choices must permeate all of the deliberations
on new categories or reformulations of categories. He argues with Sadler that “a humane
revealing of the ambiguities, assumptions, value commitments, and omissions intrinsic to
the nosologic enterprise” must be revealed and analyzed. Invoking the insights of social
and political philosopher of science Helen Longino, Sadler and Agich demand more than.
simply procedural transparency:
Through revealing these commitments a social, intersubjective process of
critical evaluation is demonstrated. This social process (debate, both
professional and public) is the means to assure a reasonable balance of
competing values and, indeed scientific objectivity. Not a naive realist
objectivity, to be sure, but an objectivity established through
intersubjective agreement and validation, and characterized by an
awareness of the competing social and historical interests that too-often
invisibly determine scientific results and “progress”. It is this revealing of
sociohistorical value commitments that is the important role of

philosophical analysis in science as well as critical analysis of psychiatric

nosology.26

As I present my own pr0posal on how to achieve these theoretical conditions, I will

characterize their demands for a sophisticated and intersubjective form of scientific

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objectivity as being synonymous with a sophisticated nosological pragmatism that
includes several ethical components.

Unfortunately, neither Agich nor his colleagues go very far in developing these
ethical theoretical demands and dimensions. It is true Agich had previously and correctly
recognized that nosological construction and psychiatric diagnosis are a matters of
practical ethics, but this insight is downplayed as a central feature of his pragmatic theory
(at least as it is articulated in his 1997 paper). 27 As I will argue, in making transparent
the practical goals of the classification of mental illnesses not only will a more
philosophically coherent nosology be made possible, but also'a more ethically defensible
classificatory scheme can be developed. Thus, one of the most important consequences of
an explicitly pragmatic nosology of mental illness will be that it will demand more
transparency about the social and political values and the historical or traditional
expectations that may drive the classification of a particular constellation of behaviors as

a mental illness (or not).

Banja ’s Pragmatic Theory

In a paper published adjacent to Agich’s 1997 commentary on Boorse, John Banja
makes the stronger claim that “disease” is not even definable."28 Instead, for Banja, the
concept of disease is an umbrella term that “embraces a number of clinical entities or
conditions that are related.”29 The wide and fuzzy—edged penumbra of ‘disease’ casts
over large swaths of socially recognized behaviors, making them worthy or deserving of
medical attention. Banja, therefore, argues that disease is better understood and explained
according to Rorty’s concept of a “web of beliefs” or Wittgenstein’s notion of family

resemblance. This is to say, the question of whether something is a disease or not

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depends on the context within which this question occurs and not on some essentialistic
quality that refers to a discrete reality.

Banja points to Rorty’s insight that any attempt to develop a correspondence
theory of reality is impossible to achieve without taking a God’s eye view of that
particular reality—~—a perspective that is impossible to achieve. Similarly, Banja, citing
neuroscientist Mark Johnson, argues that our understanding of core concepts such as
disease turn on our knowledge of semantic prototypes. Thus, according to Banja, our
understanding of diseases is not definable by a set of necessary and sufficient conditions.
Rather our understanding is governed by experiences with an amalgam of prototypical
members of the category. Moreover, social value is prior to the concept of disease in that
it motivates the investigation into physiological events of interest: “Diseases do not share
an essence, but rather form a family, loosely associated by certain pathophysiologic
events expressing themselves as signs and symptoms that a particular society deems
undesirable.”

As Wittgenstein famously argued, we can recognize diverse activities such as
poker, baseball, or Olympic curling as belonging to the same family (game) because they
resemble one another in various and particular ways. However no one criterion can be
found to define the concept of game; thus game is a blurry concept. Wittgenstein goes on
to say that a game is a concept with blurry edges, but is good enough in our common use
of language to provide what is needed. Consider the set: atherosclerosis, HIV/AIDS,
bipolar disease, infertility, and post-traumatic stress disorder. It would be diffiCult to
articulate a common characteristic that makes all these diseases. One might be tempted

to claim they are all bad things. But infertility might be a good thing to a person who is

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not interested in having children. Likewise, we might want to claim they are all
frustrations of species typical functioning. But, in the case of PTSD, this explanation
relies on empirical evidence that it is maladaptive to exhibit stress responses after a
traumatic experience. One could as easily argue from an evolutionary perspective that it
is adaptive to be on heightened alert to threats, especially after experiencing such threats,
and that PTSD is a natural artifact of this adaptation.

The Wittgensteinian point, endorsed by Banja, is that discovering a shared set of
necessary and sufficient conditions for “diseaseness” is impossible. We should accept the
fact that no one essential characteristic is shared across an array of conditions we
consider to be diseases. Banja argues that this is okay. Family resemblance is the best we
can do. Thus, we should settle on the nosological concepts that have the most pragmatic
value based on partial overlap of sets of characteristics, despite their blurry edges. This
general approach is reflected in a similar theory developed by Sadegh-Zadeh (2008), who
describes his approach as an attempt to reconcile the current stalemate between classical
concepts (essentialism) with the nonclassical reality of psychiatric disorder. 30 Like
Wittgenstein, Sadegh-Zadeh thinks that mental illnesses are not natural kinds and
psychiatric disorder should be considered “fuzzy sets” which are “a collection of objects
with grades of membership. In contrast to a classical set, it does not have sharp
boundaries between members and nonmembers.” 3}

With Agich’s and Banja’s pragmatic theories now sketched, we are encouraged to
think of mental illness not in terms of essences, but rather in terms of clusters of
phenomena that are related in the way they manifest in the language and the practice of

medicine. Their theories provide us with guidance on the practical markers that should

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be recognized in the development of an adequate classification system. However, both
theories provide little guidance about the ethical dimensions of diagnosis and
classification of mental illness. Developing an ethical account of how the pragmatic

theory ought to be applied is what we must do next.

Identifying Theoretical Gaps

So far we have seen that Agich’s pragmatic theory offers resources to both
account for and refine the pragmatic assumptions that are part and parcel to the language
of medicine and arguable built into the DSM. Similarly, Banja’s pragmatic theory
emphasizes the importance of medical practice in understand its core concept. As we now
also see, underneath both Agich’s and Banja’s pragmatic theories rest a set of
pretheoretical notions about what diseases is. And although both pragmatists would
resist the question about the true nature of diseases, which takes us back into
metaphysical territory, an understanding of these commitments is important in
developing an ethically defensible pragmatic theory. This is to say that the ontological
status of mental illness is in some sense bound up with how we ethically deal with it in
practice. For both Agich and Banja, disease is a “practical kind” that should be defined
in terms of what that concept offers toward the goal of relieving human suffering.32

Although aforementioned pragmatic theories of mental illness do a nice job of
describing their “ontological” commitments, they do not offer any normative content to
help us determine how they should be applied. Let us now begin our synthesis of these
theories with what I believe are several crucial ethical components that will fill in the
normative gaps. I will sketch these ethical components here and then detail them in

chapters 4 and 5.

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First, current pragmatic theories of mental illness fall short because they fail to
clearly distinguish between the concepts of mental disorder and moral vice. This
deficiency might be understood as a failure to provide a framework for the proper scope
of the theory. Neither Agich’s nor Banja’s pragmatic offerings provide any internal
guidance for the appropriate application of the theory to a constellation of questionable
behaviors and thus we are left questioning which instances of socially dysfunctional
behaviors are better considered to be vice, mental illness, or both. Thus, these theories
lack the key components to test whether a constellation of socially dysfunctional
behaviors should be medicalized and therefore included within the domain of psychiatry
or treated as social problems that should be delegated to other professionals or, more
likely, simply left completely untouched.

Related to this deficiency are several other missing normative components of a
comprehensive pragmatic theory of mental illness. These components rely on a set of
undeveloped ethical subtheories, which would help provide the necessary value
judgments about what should fall within the domain of the pragmatic nosology. I
envision these missing normative components as operating at several interdependent
levels of psychiatric practice. First, they would serve as a guide for individual
practitioners to navigate the ethical straits of psychiatric diagnosis. Therefore, this ethical
dimension of the pragmatic theory will provide a description of several core virtues of
individual practitioners who are charged with the diagnosis of patients. A second new
theoretical component would provide an ethical framework to classification task forces
and working groups. At this more macroscopic level, a comprehensive pragmatic theory

will make ethical demands on the professional bodies within psychiatry and psychology

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that are tasked with developing the classification criteria and diagnostic categories. Third,
the components of an ethically robust theory of mental illness will be informed politically
in that they should provide insight into the power structures that are at work in the
development and deployment of pragmatic inclusion of behaviors in the psychiatry
nosology. Finally, a robust pragmatic theory of mental disorder should also have a strong
historical component, which supports and complements the political subtheory, such that
nosologists are keenly aware of the past uses (and abuses) of medical diagnosis. Let us
now begin to unpack these various components of our new pragmatic theory and then, in
Chapter 6, provide a casuistry of how they unfold in providing both explanation and

guidance to actual cases of psychiatric diagnosis of boundary cases.

 

1. There is a plethora of studies on brain morphology and schizophrenia. See for example: R.M.
Shapiro, “Regional Neuropathology in Schizophrenia: Where Are We? Where Are We Going?”
Schizophrenia Research 10, no. 3 (1993): 187-239; Natalie L. Voets, Morgan Hough, Gwenaelle Douaud,
Paul M. Matthews, Anthony James, Louise Winmill, Paula Webster, Stephen Smith, “Evidence for
Abnormalities of Cortical Development in Adolescent-onset Schizophrenia,” Neurolmage 43 no.4 (2008):
665—675.

2. Andrew E. Skodol, Larry J. Siever, W. John Livesley, John G. Gunderson, Bruce Pfohl,
Thomas A. Widiger, “The Borderline Diagnosis II: Biology, Genetics, and Clinical Course,” Biological
Psychiatry 51, no. 12 (2002): 951-963; F .D. Juengling, C. Schmahl, B. HeBlinger, D. Ebert, J.D. Bremner,
J. Gostomzyk, M. Bohus, K. Lieb, “Positron Emission Tomography in Female Patients with Borderline
Personality Disorder,” Journal of Psychiatric Research 37, no. 2 (2003): 109—1 15.

3. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders 4th
ed., text rev. (Washington, DC: American Psychiatric Press, 2000).

4. World Health Organization, The 1CD-10 Classification of Mental and Behavioural Disorders:
Diagnostic Criteria for Research (Geneva: WHO, 1993).

5. Theodore Millon and Roger Davis, Personality Disorders in Modern Life (New York: Wiley,
2000), 9-10.

6. lbid., 68.

7. George J. Agich, “Evaluative Judgment and Personality Disorder,” in Philosophical
Perspectives on Psychiatric Diagnostic C lassification, ed. John Z. Sadler, Osborne P. Wiggins, and
Michael A. Schwartz (Baltimore, MD: Johns Hopkins University Press, 1994), 244.

8. George J. Agich, “Toward a Pragmatic Theory of Disease in Humber,” in What is Disease?, ed.
James M. Humber and Robert F. Almeder (Totowa, NJ: Humana Press, 1997), 221-246. '

9. George J. Agich, “Disease and Value: A Rejection of the Value-Neutrality Thesis,” Theoretical
Medicine 4, no. 1 (1983): 27-41.

10. George J. Agich, 1994.; John Z. Sadler, George J. Agich, “Diseases, Functions, and
Psychiatric Classification,” Philosophy, Psychiatry. and Psychology. 2, no. 3 (1995):219-23 l .

ll. Agich, I997, 226.

88

 

12. As detailed in Chapter 1, 1 am using the terms ‘normativist’ and ‘strong normativist’ to
describe those theorists who argue the concepts of health, disease, and illness are value-laden. Agich, in
contrast, uses this same term to refer to theorists whose theories aim to distinguish between value-neutral
functions and social values, such as Boorse, Wakefield and Szasz.

13. Agich, 1997, 235.

I4. lbid., 235.

15. lbid., 237.

16. For a clearly written account of this case see Ronald Bayer, Homosexuality and American
Psychiatry: The Politics of Diagnosis (Princeton, NJ: Princeton University Press, 1987).

17. John 2. Sadler, Yosaf F. Hulgus, and George J. Agich, “On Values in Recent American
Psychiatric Classification," Journal of Medicine and Philosophy 19, no. 3 (1994): 261—277.

18. John Z. Sadler, Yosaf F. Hulgus, George J. Agich, “Hindsight, Foresight, and Having it Both
Ways: A Rejoinder to R.L. Spitzer,” The Journal of Nervous and Mental Disease 189, no. 8 (2001): 495.

19. American Psychiatric Association. 1987. p.xxii as cited by George J. Agich, “Evaluative
Judgment and Personality Disorder,” in Philosophical Perspectives on Psychiatric Diagnostic
Classification, ed. John Z. Sadler, Michael A. Schwartz, M., and Osborne P. Wiggins, (Baltimore, MD:
Johns Hopkins University Press, 1994), 235.

20. Sadler, et al., 2001, 495.

21. lbid., 494.

22. Robert L. Spitzer, M.D. “Values and Assumptions in the Development of DSM-III and DSM-
lll-R: An Insider’s Perspective and a Belated Response to Sadler, Hulgus, and Agich’s ‘On Values in
Recent American Psychiatric C lassification’,” The Journal of Nervous and Mental Disease 189, no. 6
(2001): 353.

23. lbid., 354.

24. American Psychiatric Association. DSM-V: The Future Manual.
http://www.psych.org/MainMenu/Research/DSMIV/ DSMV.aspx (accessed March 2010)

25. Sadler, et al., 2001, 496.

26. Sadler and Agich, 1995, 229.

27. Agich, 1997, 1994.

28. John D. Banja, “Defining Disease: Praxis Makes Perfect," in What is Disease? ed. James M.
Humber and Robert F. Almeder (Totowa, NJ: Humana Press, 1997), 249-268.

29. lbid., 251.

30. Kazem Sadegh-Zadeh, “The Prototype Resemblance Theory of Disease,” Journal of Medicine
and Philosophy 33, no. 2 (2008): 106-139.

31. lbid., 121.

32. For an in-depth discussion of practical kinds see: Peter Zachar, “The Practical Kinds Model as
a Pragmatist Theory of Classification,” Philosophy, Psychiatry, & Psychology 9, no. 3 (2002): 219-227; lan
Hacking, The Social Construction of What? (Cambridge, MA.: Harvard University Press, 1999).

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CHAPTER 4

A PRAGMATIC THEORY OF PERSONALITY DISORDER

Introduction

In this chapter, I propose what I take to be the key distinctions of a comprehensive
pragmatic theory of mental disorder. As I have argued, current pragmatic approaches to
both defining and understanding mental illness have provided a valuable starting point.
They move us beyond the limitations of restrictive theoretical approaches that Often
conflict with our day-tO-day intuitions about mental illness and disorder. Moreover, they
aim to expose the norms, biases, and practical trade-Offs that have been a part of the
classification process itself. Also, as I described in the previous chapter, both Agich’s and
Banja’s theories offer several resources that, when used in combination with naturalistic
theories of mental illness, can provide a coherent pragmatic metatheory Of mental illness
and for, in particular, those cases which are the subjects of this dissertation~personality
disorders.

Notwithstanding these advantages, current pragmatic theories Of mental disorder
do not Offer the resources to make the important ethical choices about what kinds of
behavioral signs should be viewed as potential mental disorders in the first place.
Additionally, as we have just seen, past editions Of the DSM and the future DSM-V offer
definitions Of mental disorder that are explicitly pragmatic. Current pragmatic theories Of
mental disorder are ill-equipped tO provide a robust ethical analysis Of the codebook’s
pragmatism. For example, in addressing the ascription of the label “mental disorder” and

the development Of new diagnostic categories, the DSM-V draft definition Of mental

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disorder, released during the writing of this dissertation, includes several “considerations’
including the following:
When considering whether to add a mental/psychiatric condition to the
nomenclature, or delete a mental/psychiatric condition from the
nomenclature, potential benefits (for example, provide better patient care,

stimulate new research) should outweigh potential harms (for example,

hurt particular individuals, be subject to misuse)1
We should note that it is unclear whether this particular consideration (or the others
listed) should be viewed as a necessary or sufficient condition for adding or deleting a
condition in the DSM-V. It is unlikely that satisfying this practical consideration would
be sufficient for expanding or contracting the nosology; if it were sufficient, the range of
possibilities for inclusion in the DSM would be incredibly broad. When understood as a
necessary condition, however, this consideration offers a simple test for proposals to
expand or contract psychiatric nosology. It is clear that the trade-off described in the
statement is explicitly pragmatic and utilitarian. The consideration also implicitly accepts
the notion that there may be good reasons for the medicalization of particular behaviors,
which may or may not be directly linked to biological dysfunction and, as such, are not
core cases of mental dysfunction. Conversely, the consideration suggests that particular
behaviors should be overlooked even if a compelling case can be made they are mental
disorders. Such would be the case in instances when the ascription of mental disorder
would cause more harm than good because it would be vulnerable to abuse or the '
negative consequences of the stigma, which would be worse than the suspected mental

disorder itself.

91

While I agree with the spirit Of this consideration, it raises several fiindamental

questions such as:

By which specific criteria shall we ascribe the label of mental disorder to a
particular ‘constellation of behaviors"?

How might we ‘unitize’ or reify constellations of behaviors without begging
the central question of whether those behaviors are disordered or not?

How might we identify the behaviors that will constitute a ‘mental/psychiatric
condition’ versus instances of moral failing, vice, criminality or social
problems?

How might the process of ascription proceed in an ethically justifiable way
(i.e. what are the ethical requirements for the pragmatic ascription of mental
disorder)?

And, finally, how can we prospectively estimate the various harms and
benefits resulting from the ascription of mental disorder or its

demedicalization?

All of these questions require a more comprehensive pragmatic theoretical underpinning,

which I will begin to describe in this chapter.

In order to distinguish between pragmatically defined instances of mental disorder

and other kinds of behaviors, we need to first decide how to recognize and define the

“units of behavior” in question. I have been referring to these as “constellations of

behaviors of concern” or simply “constellations of behavior.” To more carefully identify

and describe constellations of behaviors that will be subjects of my pragmatic theory, I

will triangulate between the following: (I) the identification of a specific form of mental

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suffering, (2) a recognition that the end of medicine is the relief of this specific form of
suffering experienced by patients and that this goal should also include protecting other
people fi'om the suffering caused by the disorder, and (3) deciphering the habits that
might cause such suffering as a way to understand, classify, and alleviate the suffering.
Since a complex web of habits composes personality disorders, I will describe how
particular suffering-causing habits hang together within the larger unit of disordered
behavior. I begin tO illustrate these behaviors with brief case vignettes.

I will then turn my attention to an examination of the distinction between vice and
mental disorder. This task is crucial so that the pragmatic theory is not so broad that it
includes behaviors that are better understood as simply vicious or immoral. One
commonsensical way to distinguish between vices and mental disorder is to examine a
person’s capacity for both self-control and capacity for free choice. In short, when
dysfunctional actions are taken “freely” they are to be considered vicious, while those
taken by individuals with compromised capacity or autonomy are indicative of disordered
behavior. However, as I will argue, taking this tack to answer what is essentially a
question about free will shall prove to be less fruitful than one might initially imagine.

My alternative claim will run along the same philosophical tracks as William
James’s and other pragmatist’s responses to questions related to determinism and free
will. Thus, I will aim to move beyond these standard philosophical poles to show the
practical advantages of shifting our attention away from traditional theoretical concerns
toward verifiable and predictable positive results of inclusion or exclusion of behaVioral
constellations within a pragmatic nosology. I hope to show that the distinction between

vice and mental illness will have less to do with assigning blame or any purported

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essential differences between the two concepts, but will instead rely on the “cash
value”——to use James’s terminology—of defining our nosological categories differently.
This payout will, in turn, depend on the medicine’s potential capacity to minimize
suffering in the cases in question. Likewise, the same pragmatic judgment must, by the
same token, consider the potential harms of shifting behaviors from what might be better
perceived as part of the domain of personal responsibility. A more precise balancing of
the harms and benefits associated with blame and exculpation is an essential feature of
the ethical—pragmatic nosology I am proposing. Such a balancing act, we will see,
requires an accurate accounting of the harms and benefits that might be ascertained
through ongoing empirical investigation in both the social and natural sciences.

My third broad theoretical concern, which I postpone until Chapter 5, will be to
articulate a set Of ethical-pragmatic principles and key virtues that will empower both
individual mental health professionals and professional groups to more fully comprehend
the ethical implications Of their diagnoses and categories. To do this, I will propose a set
of important ethical criteria that should be in place to guide diagnosis and classification
efforts. These criteria will help to cordon off mental illnesses from social problems more
generally, but also ensure that medicalization of questionable behavioral constellations
happens for the right reasons. Of course, defining and defending what I mean by
“medicalization for the right reasons” will take some time and will be illustrated in case

studies and policy proposals in chapters to follow.

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Vignettes

Before turning to the theoretical underpinnings of a pragmatic approach to
categorizing personality disorders, let us begin with two case narratives. Hopefully these
will serve to provide empirical (albeit anecdotal) anchors for the philosophical arguments
that I will offer in this and following chapters. These vignettes are culled from both
popular and academic sources and provide a glimpse into the world of people diagnosed
with Cluster B personality disorders—~a broad category that includes “dramatic,
emotional or erratic disorders.” 2 There are four Cluster B personality disorders:
antisocial, histrionic, narcissistic, and borderline. The stories begin to illustrate several
common behavioral features and dysfimctional interpersonal dynamics that often

accompany borderline personality disorder.

Laura (diagnosed with borderline personality disorder)
When my two-year-Old wants something, she wants it now. When I am
shopping I can’t tell myself no, so I buy it, even though I’m in debt. To a
child, the most important thing is security and safety. For me, safety
means being what others want me to be so they won’t reject me. The
inside stays hidden—~even to me. But under all the politeness hides an
angry, frightened toddler. My husband wants the damaged little girl inside
me to set priorities by saying, “Yes, I’m angry, but when I talk to you I’m
going to try to be reasonable.” You wouldn’t ask that from a real two?

year-Old, so don’t ask that from me, either. It’s not that I don’t want to. I

just can’t.

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Jacqueline (diagnosed with borderline personality disorder)
Anthony, an intern who had just gotten married, describes a conversation
with his wife, Jacqueline when he announced he was going for a run: “I
am off, darling,” I told Jacqueline, who lay burrowed in her duvet. “Where
to?” she asked. “For a run. Look at this, I am getting fat.” I wobbled my
gut in front Of her, laughing. “SO what?” “What do you mean?” “So what
if you're getting fat?” “I need to lose some weight.” “Who are you trying
to impress?” “Nobody, it's just a healthy thing to do. Anyway, my pants

’3 6‘

are getting tight What's wrong with all you men? You think that you
have to have rock hard bodies to get the chicks. That's not what women
want. That's not what I want. I want you to take care of me. I want you to
make so much money that I never have to work, and that we can go to
restaurants whenever we want. I don't want some pansy prancing around
in his tights.” “What's gotten into you? This isn't some vanity trip. I'm just
going for a run.” “So it is more important to you to go for a run than to be
with me?” “What are you talking about? I am with you. I'll be back in half
an hour” Jacqueline took a half-empty wineglass from the nightstand and
smashed it to the ground. “What the hell are you doing to me? You
promised me that you would never leave.” I shuddered and stepped back

from her. She started to cry. “You are doing that now. You promised that

you would never leave me.” I went to hold her.

96

it:

In both vignettes, we see several features common among patients with borderline
personality disorder, ineluding impaired impulse control, intense anger, a frantic reaction
to the perception that they will be soon abandoned and an arrested sense of personal
identity. We also find reflections of the inter- and intra-personal strife and alienation that
seems to emerge from pervasive patterns of dramatic, petulant behavior and emotional
lability. With Jacqueline, for example, we see the characteristically hostile, angry, and
aggressive behavior that leaves Anthony perplexed and doubting his own intentions. In
fact, this is a common feature of borderline disorder whereby friends and family are left
wondering what they might have done wrong and if there is some truth to degrading
claims made by their borderline relative. Compounding the confusion, these behavioral
patterns seem to straddle the line of intentional and unintentional, have been described as
habitual coping devices borne out of childhood abuse or neglect, and are both self-
destructive and have a profoundly negative impact on others. As I will argue below, each
instance of habit marks an individual point from which the larger constellations of
behavior begin to take shape. Though, as we shall see in chapters 6 & 7, a deeper
examination of cases such as these may reveal particular biases or gendered
presuppositions about normalcy that problematize our analysis, let us keep these cases in
mind as we begin to think about how our pragmatic theory of mental disorder should
account for these patterns of behavior.

It is important to also consider, although not explicitly illustrated in the vignettes,
the particular form of pain that sufferers of personality disorders experience. For ‘
example, studies on the subjective experience of their pain reveal that borderlines tend to

experience a cluster of dysphoric states rooted in extreme feelings, self-destructiveness,

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fragmentation, ‘identitylessness’ and victimization.3 In the case of Laura, we might

surmise that her pain is the result of a deep sense of vulnerability——she is unable to feel
secure as an adult and retreats back into the vulnerable role of a child. Likewise, with
Jacqueline, her suffering seems to be rooted in an all-pervasive fear of abandonment.
Depending on the one’s psychological orientation, Laura’s and Jacqueline’s behavior
might be framed in terms Of a distortion in object relations, splitting or identity diffusion
(psychoanalytic), a fundamentally flawed schema causing irrational self-talk (cognitive-
behavioral) or an imbalance of neurotransmitters (neuropsychology).

To more fully examine these concepts, let us look first at these behaviors through

the lens of the unique form of suffering they might cause. In doing so, I hope to then be

able to argue that this is a form Of suffering that psychiatry is appropriately equipped to

relieve.

Suflering & the Ends of Medicine
In chapter 2, we saw that social dysfunction is part and parcel of a personality
disorder and can be thought Of as analogous to the biological dysfunction concepts of
naturalists like Boorse. Although brief and anecdotal, it is reasonable to suggest that the
above vignettes illustrate there is something dysfunctional in the behavior of the
antagonists, especially when we assume these short narratives are a mere snapshot of a
larger pattern. A challenge in cases of social dysfunction is first pinpointing the behaviors
(or cognitions, which for our purposes will be considered behaviors of thought) that
constitute said dysfunction. It is much easier, for example, to observe a hole in a

chamber of the heart and identify the dysfunction of the organ. To critically examine a

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dysfunction in patterns of behaviors we must decompose the constellation of behaviors
that seem intuitively to be dysfimctional ones, which coalesce to form the complex kind
of social dysfunction constituting personality disorders.

Let us, therefore, first consider a constellation of behaviors as circumscribed by a
particular set of habits———to be described below as our working ‘unit’ of behavior——that
cause a particular kind of suflering. Thus, the constellations of behaviors we are most
interested in are those that cause suffering or anguish that is unique in some way to other
kinds of suffering. As we will see, this suffering might be experienced by the individual
exhibiting the behavior, their family, the community, all of them or just a subset of them.
Although physicians are concerned with the suffering of individual patients, we can
understand personality disorders through the lens of public health, since others who are
close to the patient experience their ill effects. Moreover, the form of suffering to which
I am referring may be exacerbated by social, political and economic conditions. Thus, the
ways in which what Arthur Kleinman calls “social suffering” might instantiate and be
experienced is varied and diverse. In thinking about the form Of suffering caused by
mental disorder we must remember, as Kleinman and Kleinman argue, suffering is a
social experience, which we should avoid “essentializing, naturalizing, or

sentimentalizing. There is no single way to suffer; there is no timeless or spaceless

universal shape to suffering.”4

That being said, the theory I am proposing could not simply attend to behaviors
that cause any and all forms Of suffering. For example, we would not consider the
“suffering” many of us experience while waiting impatiently in a traffic jam at the end of

a long workday as the kind of suffering that matters for our analysis. This form Of

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suffering should intuitively strike us as being, in general, outside our domain of inquiry.

While it is unpleasant, it would not be the form of discomfort that should be a candidate

for medical interventions Similarly, the kind of suffering caused by particular
misfortunes such as driving an unreliable car or living in a house with a leaky roof is
outside the domain of medicine. It is simply not a doctor’s job nor is it within her area of
competence to repair your car or fix your roof.

In contrast, for example, we will want to attend to the kinds of mental or

emotional anguish that accompany episodes of depression. This kind of suffering can be

palliated by several kinds of medical modalities such as Prozac and psychotherapy.6
There are certainly potential nonmedical remedies such as stress reduction workshops or
a long vacation in a warm place. But the fact that medicine offers curative resources as
possibly more efficacious alternatives satisfies the necessary condition that we are
dealing with a form of suffering that might be rightly considered a medical disorder.
Meeting this necessary condition provides the starting point for supporting the claim that
conditions similar to depression should fall within the domain of medical disorder.

The capacity of medicine to relieve distinct forms of suffering is a necessary,
though not sufficient, condition for the medicalization of a particular set of problematic
behaviors. Additionally and importantly, there are forms of suffering that are deserving Of
medical attention but for which medicine still lacks the resources to fully relieve. In these
cases, we consider the potential for medicine to relieve these forms of suffering as
justifying them as medical problems. Thus, the healing capacity of medicine can be
imagined in potential treatments yet to be developed or discovered. Recognition of this

prospective capacity to relieve suffering is based on the fact that medicine is both a

100

healing art and a scientific enterprise and we have the experimental methods of science to
ground hypothetical inquiries into medical advances. We see the scientific enterprise at
work in the search for cures to cancer, vaccines to prevent HIV/AIDS, and research into
autism. It is thus the healing capacity of scientific medicine—in the present or future-
that helps us to recognize the specific forms of suffering that are medically remediable
and forms that are outside the current or future domain of medicine.

The position of personality disorders along this continuum of suffering—ranging
from the nonmedical (leaky roof) to the obviously medical (cancer)——can therefore
arguably be tied to an assessment of whether medicine has or will have the tools to
relieve that suffering. Some might argue that because the answer to this question is
historically and culturally relative it renders whatever problems medicine attends to as
being purely relativistic artifacts of time and place. I would not take issue with this
objection. The focus of medicine depends on the state of medical technology,
pharmacology, psychotherapy, etc. and a society’s ability (or willingness) to deploy those
resources. As a pragmatic theory, the technological and scientific sophistication of a
society is simply a reality that must be taken into account. However, as I will describe
below, several ethical caveats will be offered to provide guidance about how and why
medicine should address particular forms of suffering if resources are indeed available.
These more normative questions will require case-based analysis and ethical argument.
For now, I propose a more straightforward account of why and how we might determine
which forms of suffering matter for building the comprehensive pragmatic theory. The

key will be to first identify those forms of suffering, for which medicine is equipped to

101

 

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relieve. Thus, I am targeting ‘behavioral constellations’ that cause a particular species of
suffering—one that intersects with the traditional ends of medicine.

What are these traditional ends of medicine? Here we circle back to a naturalistic
account of disease and function, and look to Pellegrino for a useful definition: “Within
the traditional ends of medicine, the primary intention is the use of biotechnology to treat

physical or mental disease... The patient feels ‘better’ and regains functional capacity.

He may be returned to his previous state of health, or to an even better state.”7 Pellegrino
defines the ‘ends’ of medicine in essentialist terms in contrast to the ‘goals’ of medicine,
which he believes are socially constructed and instrumental. He believes that the ends of
medicine are intrinsic and universal to the healing profession and are actuated by
individual physicians who abide by agreed-upon practices to achieve those ends. Thus,
“physicians do not determine the ends of medicine; it is their task to realize these ends in
a specific clinical encounter with a particular patient. Physicians are charged with
ascertaining, together with the patient, the content of the end of healing.”8

Pellegrino argues that the ends of medicine must never be subsumed by the goals
or purposes of medical practice. Thus, the universal quality of the ethical healing
relationship, about which he has extensively written, should determine the means of
medical intervention and not vice versa. Pellegrino is wary of medical goals undermining
the integrity of medicine by usurping the internal ends for pragmatic purposes. He cites
the well-known cases Of Nazi and Soviet medicine as historical examples of the ends-
goals inversion. He reminds us, “whenever medicine is used for any purpose or gOal—

however defined—that distorts, frustrates, or impairs its capacity to achieve its proper

ends, it loses its integrity as a craft and its moral status as a human activity.”9

102

Make no mistake; ~Pellegrino’s theory of the ends of medicine is anything but
pragmatic. It is essentialist to its core, so it might seem strange I wish to call on it to
build a comprehensive pragmatic theory. However, Pellegrino’s argument is helpful for
two reasons. First, as will become clearer, it reminds us to be cautious of creating a
pragmatic theory of mental illness that overreaches. Pellegrino’s cautiousness and
conservatism on defining the true ends of medicine will be helpful in thinking through the
moral boundaries that will be needed for an ethically justifiable pragmatic theory.
Second, in defining the constellations of behavior that concern us for our theory, we
should orient ourselves toward an ‘end’. In contrast to Pellegrino’s theory, our concept
of ‘end’ is not an intrinsic telos that is somehow metaphysically embedded in the practice
of medicine. For our account, this end is simply the pragmatic goal to ameliorate and
prevent a particular species of human suffering. Therefore, the concept Of the ends of
medicine I am endorsing looks superficially much like Pellegrino’s. Substantively,
however, it is diametrically opposed. The concept of the ends of medicine I endorse is
simply a heuristic device to help anchor the theory’s other foundational concepts. It is a
completely instrumental concept in that the ‘ends of medicine’ only exist insofar as they
prove useful to us. This shift also entails instrumental goals of medicine might at times
supersede our pragmatically defined end.

At first blush, another key difference between my account and Pellegrino’s would
seem to be that his theory is based on the central argument that the suffering to which
medicine should exclusively attend is that of individual patients. For Pellegrino the end
of medicine is for physicians to relieve the suffering of their patients; the benefits of

medical intervention for others are considered secondary and should never constitute the

103

primary motivation for that intervention. However, it would seem Pellegrino would grant
exceptions for involuntarily treating severely mentally ill individuals who pose a physical
threat to other people. In these cases, the ideal end of medicine cannot be easily (or
safely) achieved. In fact, the threatening individual might not be suffering at all, and,
moreover, any medical intervention would actually cause them to suffer. In these cases,
for the public’s good, the instrumental use of medicine must guide our actions and the
patient must be treated for the primary goal of ensuring public safety. It is at this juncture
that I believe our accounts parallel. As I shall argue and illustrate through case studies,
particular personality'disorders present a unique risk to the public health such that we can
and should consider the welfare of others in our process of categorizing these behaviors
as medical problems. Granted, for personality disorders, involuntary treatment is
generally not justifiable particularly because the threat they pose to others is not as grave
as cases of extreme psychopathy. However, at the same time, the public health
perspective can justify the provision of medical resources to those who are adversely
affected by people with personality disorders.

Before considering the public health dimensions of the pragmatic theory of
mental disorder, let us return to nosological issues related to diagnosing individuals. By
understanding the end of medicine as aiming to relieve a specific kind of mental and
physical suffering, we can then begin to parcel out behavioral constellations that deserve
medical attention. At this point, our theoretical account of “behavioral constellations”
does not yet provide a complete picture with enough theoretical relief to recognize
questionable behaviors from the background of quotidian activities of life. To achieve

this, it seems we need a more discrete behavioral unit to serve as our referent, so that

104

when examining instances of suffering, some of those units might rise above the noise of
everyday activities to become behavioral constellations of concern. We need something

to point to in order to build our pragmatic nosology. That something will be habit.

Habit

The needed resources to more clearly define the concept of ‘behavioral
constellation’ can be found within William James’s and John Dewey’s expansive corpus
on social psychology. Three sources will prove especially useful for this task— Dewey’s
early papers on the philosophic dimensions of psychology, James’s Psychology, and
Dewey’s Human Nature and Conduct. Across both Dewey’s and James’s functionalist
psychology are common pragmatic threads supporting empiricism and naturalism, a
rejection of mind/body dualism, and the belief that all human behavior is marked by the
interaction between the individual and both their natural and social environments. These
theoretical fibers, when woven together, provide the starting point for identifying
behaviors of concern as being empirical realities that individuals outwardly and
habitually exhibit. Thus, ‘behavioral constellations of concern’ should be recognizable
patterns and be scientifically verifiable, measurable, and predictable in much the same
way as physiologic responses. This analogy will also be crucial for attaching my
pragmatic theory to Boorse’s naturalism at the juncture between the concepts of
biological and social dysfunction.

' In fact, Dewey’s influential paper “The Reflex Arc Concept in Psychology”
extends the analogy between mental states and functions and autonomic physiological

functions. In that paper Dewey argues that the physiologic concept of the reflex arc was

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misunderstood and this resulted in a similar misunderstanding of psychological functions.
For Dewey, the stimulus and response is a single circular unit and not a disjointed are, as
had been earlier described by structuralists who viewed the stimulus-response (or
stimulus-mental state) dyad as a linear cause and effect. In contrast, Dewey’s was a
functional account, which explained behavior according to the contemporaneous
coordination between phases of stimulation and response; an insight that provided the
intellectual basis for development in social psychology.

Understanding responses as continuous with stimuli will help to clarify——but also
complicate——-the determination of units of behaviors. For example, when we consider the
borderline personality disorder, we will see that the behaviors often associated with the
disorder, such as impulsivity and manipulation, cannot be easily disentangled from the
social structures that might have partially caused or continue to reinforce those behaviors.
In other words, the behaviors we are concerned with are not simply reflexive reactions to
stimuli. Dewey’s notion of the interdependence of the stimulus-response allows us to
begin to think about various behaviors—albeit reflexive ones—as part of a larger
psychological and social context. Contextual analysis of particular behaviors is critical to
understanding the etiology and current classification of personality disorders, since as we
now know, the DSM defines personality disorders in terms of cultural expectations. Yet,
for all of its influence in social psychology, Dewey’s theory of the reflex arc in
psychology remains too basic. It only provides a way to think about simpler instances of
the stimulus-response complex. What is needed is a more robust account of personality,

one that allows us to say: “This or that set or pervasive pattern of behaviors seems

dysfunctional.”

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To build the needed pragmatic ontology of behavioral constellations we should
now shift over to William James’s Principles of Psychology, published more-or-less
contemporaneously with Dewey’s “Reflex Arc”.10 Here we find James’s theory of habits,
which is a naturalized account of both basic and complex patterns of human behavior.
For James, habits have “a physical basis” that can be identified through the basic laws of
physics governing the way structures (built up from elementary particles) react to
“outward forces and inward tensions.”H It is the plastic capacity of complex structures
of matter to bend, to stretch, and to later recover that marks the physical basis for habits
in humans. In living beings, “the phenomena of habits. . .are due to the plasticity of the
organic materials of which their bodies are composed.”12 It is this plasticity that allows
the mind to be reshaped according to a person’s repeated ways of life. Accordingly, for
James, habits become psychologically and physically imprinted. They are the tracings
found in the brain caused by particular nerve impulses repeatedly pulsing across and
through the same nervous centers. Like a river cutting its way through a canyon, the
neural imprints of habits deepen each time they are performed.

James believes that our propensity to form and perform habits can be most
advantageous. Habits save us the time and energy it would otherwise take to think
through each of our daily activities. Habits provide stability to the individual as they age
and mature. Habits are the “enormous fly-wheel of society”—-—they conserve the status
quo of social institutions and strata, arguably allowing society to function without
constant upheaval. At the individual level, the formation of healthy habits is necessary
for both basic psychological health and for achieving higher levels of productivity. We

must “make automatic and habitual, as early as possible, as many useful actions as we

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can, and guard against the[m] growing into ways that are likely to be disadvantageous to
us, as we should guard against the plague. The more of the details of our daily life we
can hand over to the effortless custody of automatism, the more our higher powers of
mind will be set free for their own proper work.”13

From his thinking on the circuitous nature of stimulus and response, and building
off of James’s work, Dewey eventually developed his own theory of habits, which he
claimed were characterized as,

an acquired predisposition to ways or modes of response, not to particular

acts except as, under special circumstances, these express a way of

behaving. Habit means special sensitiveness or accessibility to certain

classes of stimuli, standing predilections and aversion, rather than bare

recurrence of specific acts. It means will.14
For Dewey, it is the concatenation of habits that defines individual character, and we can
make sense of personal choices only by understanding habits. This is to say individual
habits drive choices in that they set up the range of foreseeable options based on
habituated “predilections and aversions.” However, these habits are not discrete but are
rather interdependent and are in fact impossible to disentangle from one another:

All habits are demands for certain kinds of activity; and they constitute the

self. In any intelligible sense of the word will, they are will. They form

our effective desires and they firmish us with our working capacities. They

rule our thoughts, determining which shall appear and be strong and which

shall pass from light into obscurity...We may think of habits as means,

waiting, like tools in box, to be used by conscious resolve. But they are

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something more than that. They are active means, means that project

themselves, energetic and dominating ways of acting. 15

As Allport notes, as Dewey’s concept of habits evolved over the decades it became

somewhat riddled with equivocation. ‘6 Nonetheless, the basic concept as described in
Human Nature and Conduct reflects one aspect of what I mean by a “constellation of
behaviors” that will be subjected to our pragmatic analysis. Indeed, within Dewey’s
social psychology, habits occupy a central role: they are a mark of function and
dysfunction. Good habits are akin to physiological functions in the way they provide for
the flourishing of the individual. In a broader sense, habits also constitute the individual

threads that make up the fabric of human community: “Our individual habits are links in

forming the endless chain of humanity.”1 7 The implication of this understanding of
habit—that they form the basis for community relations—~is important because it supports
the commonsense claim that an individual’s good or bad habits affect other peOple. And
so, we can begin to address the form of suffering that is caused by dysfunctional habits
while also recognizing the transmissible quality of this suffering. The particular

individual with the personality disorder is the primary node of this suffering, which is
transmitted, somewhat virally, to their relations.

By combining James’s theory of habits, with Dewey’s basic reflex arc concept
and his more robust theory of habits, a clearer picture of what is meant by ‘constellations
of behaviors’ now emerges. By defining constellations of behavior in terms of habits, we
not only can identify specific patterns of behavior as separable from other activities of
daily life, but also, begin to assess the dysfunctional dimensions of those behaviors. We

can now also argue that personality disorders are characterized by sets of dysfunctional

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habits. For example, when we look at borderline personality disorder, these habits will
include a propensity to react with intense anger, paranoid ideation, suicidal gestures or
threats, self-mutilating behavior, and frantic efforts to avoid abandonment.

From a pragmatic perspective, then, these dysfunctional habits include a wide
array of behaviors that continuously stifle and erode the disordered person’s interpersonal
relationships. They likely push the disordered person into social isolation making it
difficult or impossible to for that person to flourish, and causing the pathological
feedback loop Of alienation. The habitual nature of these behaviors makes them
extraordinarily difficult to change because they are embedded in the psyche of the
disordered individual. And it is both the pervasiveness and incorrigibility of destructive
habits that mark out the constellations of behaviors that are characteristic of personality
disorders. Such habits become inevitable, as they impede one’s will to think or act
otherwise. Habits typically associated with personality disorders will persist even after
repeated instances of negative feedback, therapeutic interventions, or other attempts to
retrain the patient.

How is it that such habits, which seem to be incompatible with human flourishing,
form and persist? Research into etiology of the dysfunctional habits associated with
borderline personality disorder provides evidence that they are formed in response to
severe childhood abuse, trauma, or abandonment. Though it is still unclear whether the
association between abuse and BPD is correlation or causal, the evidence is quite
compelling that both genetics and childhood abuse combine to cause “emotional ’

dysregulation and impulsivity” that are the bases of the more specific dysfunctional

behavrors, which, rn turn, amplify additional socral causes. 8 They are primitive coping

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mechanisms that are solidified in the nascent character of young persons. As such,
dysfunctional habits are more deeply embedded in the minds of the disordered adult.
Resonating James’s theory of habit, people who have personality disorders can be
described as lacking a normal degree of resilience when faced with stressors. It is this
rigidity that makes them resistant to rehabituating in more functional ways. Moreover,
the dysfimctional habits of people with personality disorders are often described as being
incorrigible. The neural tracks of the dysfunctional habits are burned into the psyche so
deeply they cannot be rerouted.

At this point, the concept of habit grades into our next set of questions. These
concern making normative judgments about the specific habits or behaviors in question.
Although I have just described some habits that can be considered to be functional or
dysfunctional depending on their pragmatic capacity to make one’s life more efficient or
easier, we still need to subject this distinction to further analysis so that we do not base

our nosology on behaviors that are better described as moral failings or vices.

Beyond ”Bad or Mad? ”

It might seem that a comprehensive pragmatic theory of mental illness that aims
particularly for understanding and better addressing the question of personality disorders
must first set out a set of criteria to determine whether behaviors in question are instances
of moral vice or potential medical problems (or both). Arguably, what is of central
importance to the nosological pragmatist is first to begin drawing lines between instances
of bad behavior and behavioral constellations that seem to be outside the control of the

individual. It seems Obvious that we would not want to include instances of vice in our

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nosology, but similarly we would not want to mistake potential mental disorders as being
simply vices. This question is sometime simplified in the philosophy of psychiatry
literature in terms of distinguishing the ‘bad’ from the ‘mad’ and volumes of
philosophical and historical research have been devoted to drawing this distinction more
clearly.

Indeed, for millennia moral philosophers have been puzzling over a way to clearly
demarcate vicious behavior fiom other disordered behaviors. As is well known,
Aristotelian virtue theory provides a model for understanding vicious behaviors as being
either a deficiency or excess of a particular property, the mean of which would be a
virtue. Virtuous and vicious persons, in turn, can be distinguished from those who are
continent (enkrateia) or incontinent (akratés); in each respective case, these people might
happen to act virtuously, without necessarily desiring to do so, or lack the willpower to
resist the inclinations of their appetites. In this context, the crux Of the ‘mad’ or ‘bad’
question is located in our understanding of the role of the will to account for the actions
of the individual. For example, the impetuous akratic person acts on their passions
(pathos) without reasoned deliberation while the weak akratic person acts in spite of and
in conflict with their reason deliberation. Both forms of incontinence mark a form of
uncontrolled or impulsive behavior that is less blameworthy than vicious actions.

In a similar way, in his Anthropology, Kant distinguishes between persons who
lack the ideal collection of moral and intellectual virtues from those whose reason and
understanding are well tuned toward acting morally. Kant argues those who are
diminished in their ability to deploy the higher faculties Of cognition (Understanding)

suffer a sickness of soul. As Kant tells us, the overarching power of Understanding

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consists of more specific elements of understanding, such as the power of judgment

(iudicium) and reason. He claims that the healthy mind is composed of “correct
understanding, practiced judgment, and thorough reason.”'9 Of course, this idea dovetails
with Kant’s moral philosophy, within which heteronomous actions are contrasted with
freely chosen autonomous action. One source of heteronomy would be Kant’s concept of
sickness of soul, which inhibits a person’s ability to separate impulse from reasoned
action. For our purposes, we might conclude that the inability to differentiate between
primitive sensual impulses and well—formed thoughts derived from human understanding
and reason may serve as the demarcation for Kant’s notions of mental illness versus vice.

As I mentioned in earlier, Foucault reexamined Kant’s Anthropology in his early
writings (including for his own dissertation on Kant’s psychology) and laid the
foundation for his well known, albeit controversial, historical-philosophical account of
how the ‘mad or bad’ question has been addressed in Western society since the Middle
Ages. The origins Of the distinction, Foucault claims, can be first located in the era
between the Middle Ages and the Enlightenment, when the mad were cast out of their
community and shipped from port to port on the Ship of Fools (Stultifera Navis) in
search of a sympathetic host community.20 The mad were marked as outsiders who were
exiled, much like lepers, from the city centers. Through the Nth-19'h century, during
what Foucault calls “The Great Confinement,” mentally ill people were confined with
criminals, vagrants, tramps, and other social undesirables. By the 1800’s, the mentally
ill were housed separately from criminals, in particular because, as William Tucker

argues, “observers who distinguished ‘mad’ from ‘bad’ had decried the fact that criminals

were forced to endure the screams of the insane, which added to their punishment.”21

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Tucker also notes that this concern was reversed by the late 1800’s by metal health
advocates and researchers such as Philip Pinel, the Tukes, and Dorthea Dix all of whom
championed providing treatment, not criminalizing, the mentally ill.

What these historical thumbnails suggest is that the answer to the vexing question
of how to cordon off vice from mental illness has most commonly turned on a theory of
free will and its allied concepts: autonomy, freedom and personal responsibility. And so
it would be unrealistic to expect a pragmatic theory of mental illness to offer a robust
solution to this debate along these traditional lines. In fact, the inability to attend to and
resolve this theoretical question conclusively is a limitation that is recognized and
actually built into our pragmatic theory. But what the pragmatic theory should do, in the
very least, is provide a satisfactory method to begin our analysis of constellations of
behavior that we might wish to consider as mental disorders. To do this, a pragmatic
reframing of the question about vice and disorder is required.

We should first recognize that the question Of ‘mad or bad’ creates a false
dichotomy that requires further (and unnecessary) theorizing. Indeed this question
pushes the answerer to reify behaviors according to a set of pretheoretical criteria, which
directly relate to a question about whether the action or behavior was freely chosen or
whether the behavior is somehow unintended and ill-controlled. Thus, the typical
response to the question of whether a person is mentally ill or simply vicious turns on the
extent to which that person should be held responsible for their actions. The ascription of

mental illness should exculpate such a person, while the identification of a behavior as a

. . 22
vrce or as immoral should render them blameworthy.

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The pragmatist would first respond that the question of whether a person is mad
or bad as it has been traditionally framed begs the central question that that person has
free will to begin with. Moreover, as James would claim, the question of free will is
irrelevant for the purposes of our inquiry and that the concept of free will itself is simply
a nominal construct, which is helpful in motivating progressive efforts (meliorism) but
theoretically undecideable.23 To wit, with regard to the sorting out of free will and
blameworthiness, James argued in his lecture “Some Metaphysical Problems” from
Pragmatism:

Instinct and utility between them can safely be trusted to carry on the

social business of punishment and praise. If a man does good acts we

shall praise him, if he does bad acts we shall punish him——anyhow, and

quite apart from theories as to whether the acts result from what was

previous in him or are novelties in a strict sense. To make our human
ethics revolve about the question of ‘merit’ is a piteous unreality—God
alone can know our merits, if we have any. The real ground for supposing
free-will is indeed pragmatic, but it has nothing to do with this
contemptible right to punish which has made such a noise in past
discussions of the subject. 24

For James, free will, as such, is nothing more than a “general cosmological theory of

. . . . . . ,,25 .

Promise, just like the Absolute, God, Spirit, or Desrgn. As a pragmatic concept
however, free will is necessary for James’s larger melioristic vision because it allows us
to hope and strive for social progress. Furthermore, the concept of free will is not meant

to be used for putative purposes. For the pragmatist, the seductive impulses to blame and

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hold accountable, when based on a notion Of free will, are really spiteful vestiges Of
human history. Again, James:
You know how large a part questions of accountability have played in the
ethical controversy. To hear some persons, one would suppose that all the
ethics aims at is a code of merits and demerits. Thus does the old legal
and theological leaven, the interest in crime and sin and punishment abide

with us. ‘Who’s to blame? whom can we punish? whom will God

punish?———these preoccupations hang like a bad dream over man’s
religious history.26
The key question that must be answered is not whether a person is blameworthy for their
behavior but whether ascribing a label to them related to their mental functioning is
helpful to that person, their family, and the larger community. Therefore, we must move

beyond the impulse to either assign blame or exculpate individuals for their actions and

consider, instead, how best to efficiently manage such behavior if it is deemed
problematic.
Let us consider a simple example to illustrate this central point: A person who is

addicted to heroin is arrested for the petty theft they committed to support their drug

habit. Some will argue that that person has committed a crime and thus should be
punished. They will claim that retributive justice requires that the thief make amends for
their crime by providing recompense to the victim or serving time in prison. Others will
claim that the person suffers from a form of mental illness—an opiate addiction Which is
both physiologically and psychologically based—and thus should be provided the

resources to be treated for their addiction. They will probably marshal empirical evidence

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about the effects of heroin addiction on the brain and show how it leads to behaviors that
are largely uncontrollable. A third, more likely, response might combine the two and
argue that the addict should be held accountable for their actions in some way, but is
nonetheless not completely blameworthy for their actions. They might propose sanctions
such as compulsory treatment with the threat of imprisonment.

Underlying each of these positions is an assumption about the addict’s degree of
responsibility and a demand for accountability for her actions. The first reply is
characteristic of a moralist who judges the addict’s behavior—both in abusing heroin and
in committing petty crimes—~as being a simply the result of a poor choice by the criminal
that was made voluntarily. The second reply might be characteristic of an addiction-as-
disease apologist who seeks to exculpate the addict for their poor decisions on the basis
that they are not in control of their actions, and thus should not be held responsible for
behaviors that are not volitional. The third seeks to blend these two. Notwithstanding
glaring exceptions, the third response is representative of what Ofien takes place in our
current criminal justice system in dealing cases addiction and petty crime.

A pragmatic response to this case would be fundamentally different than the three
I just sketched. The answer to the theoretical question regarding the blameworthiness or
volition of the heroin addict is largely irrelevant. Instead, the pragmatist will want to first
know what kind of outcomes the available Options offer, and whether those outcomes will
be beneficial to the addict and the community at large. It might be the case that it would
be best to imprison the addict for a time—not for retributive purposes but rather to both
wash out the drug and provide a behavioral deterrent for theft—and then set them on a

structured path toward addiction recovery. Or it might make better sense to forget about

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incarceration and simply provide this addict with controlled doses of methadone,
buprenorphine or heroin to eliminate future risk Of petty theft. The goal here is not to
appeal to sacrosanct principles of retributive justice, but rather to figure out what strategy
is most efficient and practically doable and which will maximize the most good for all the
stakeholders.

Nonetheless, especially for cases of Cluster B personality disorders, clinicians and
researchers remain concerned with the role of personal responsibility and frame the
question in terms of the dilemma between freedom and illness. Siever and Koenigsberg,
for example, commenting on the promise of neuroscience research on borderline, present
the dilemma thusly:

At a time when psychiatry is grounding one severe mental disorder after

another in brain biology, borderline personality disorder confronts us with

an enigma—and a clinical dilemma. We have little trouble understanding

how a man with a tumor impinging on his frontal lobes may become

irascible and display poor judgment, or how someone with an abnormal

organization of her brain may hear voices and act out of touch with reality.

But we resist seeing the moody, irritable, apparently manipulative and

willful behavior of “borderlines” in terms of the biology of the brain; it

seems to absolve them of responsibility for their aggressive, antisocial, or

even outright criminal acts. 27
In other words, according to this framing of the issue, a clinician who is treating a
borderline can embrace the biological basis of the disease, but only at a cost: that of

exculpating to some degree the patient from responsibility for her behavior. Conversely,

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a skeptic who doubts the evidence about the role of neurological dysfunction in
personality disorders will push from the other side of the apparent dichotomy. They
might argue, for example, that correlational data about the size of the amygdala should
not excuse people from acting out in ways that are socially disruptive. When framed in
this way, arguments about the nosological validity and signs and symptoms of personality

disorders grade into questions about accountably, freedom, and personal morality.
The pragmatist wants to reject the dilemma altogether and thus avoid confounding
it with moral or ethical judgments. For the pragmatist, the question related to whether a
constellation of behaviors is a vice or a mental disorder is largely irrelevant, except in the
way that determination might lead to particular consequences. This is to say, the
determination of whether to consider a constellation Of behaviors is a mental illness
should not rely on a theory of responsibility. Rather, such a determination should first
examine the nature and locus of the suffering and decide whether psychiatry has or might
have the resources to relieve that particular form of suffering. Second, the pragmatic
examiner must assess whether the ascription of ‘mental disorder’ will Offer more positive
results than ill effects. If the answer to these questions is a tentative ‘yes’ then that
constellation of behaviors might be a candidate for the label ‘mental disorder’. In the end,
the pragmatic response to the ‘mad or bad’ dilemma happens through a transformation of
the question itself into one in which an answer is actually possible, one which yields a
way forward leveraging available empirical evidence toward reaching the goals of a fully
functioning and ever-progressing community.
As I will discuss, transcending the mad or bad distinction can out both ways. We

can make pragmatic claims about how to best manage behaviors and reject the

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dichotomy—as I propose—or we can embrace both choices in the dichotomy by both
ascribing the label of mental disorder and blaming sufferers for their behavior. In other
words, we can find many examples of the tendency to accuse people with personality
disorders of a ‘willful madness’ that is the cause of their troubling behavior. Particularly
with borderline personality disorder, the ascription of mental disorder has done nothing to
preclude clinicians and nosologists from casting implicit or explicit blame on borderline
patients for their illness.

Nancy Potter cites several instances of this in textbooks, including in Millon’s in
which he tacitly lays blame on deliberate actions of patients. She says his use of scare
quotes indicates this much. I agree——and would assert this description delegitimizes the
patient’s own account Of her suffering. “Depression serves as an instrument for them to
frustrate and retaliate against those who have ‘failed’ them or ‘demanded too much.’
Angered by the ‘inconsiderateness’ of others, these borderlines employ their somber and
melancholy sadness as a vehicle to ‘get back’ at them or ‘teach them a lesson’.”28 Millon
continues on from there in a similar way. What we will see in the next chapter is such
inferences that blame sufferers of a personality disorder are antithetical to the ethical-
pragmatic goal of ascribing mental disorders for the good of the patient. This insight I
believe will further support my argument the pragmatic ascriptions of mental disorder

must resist the temptation to engage the standard debate about blame and illness, and

instead embrace outcomes based management strategies.

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Hypersexuality & the Consequences of Exculpation
The pragmatic approach to dealing with personality disorders would seek to avoid

the ethically fiaught questions related to personal responsibility as constitutive of mental
disorder or not. That said, however, the consequences that result from a perception of
exculpation should be explored. As I mentioned, in addition to maximizing the benefits
of all involved, the pragmatic theory must also account for the potential harms associated
with relieving individuals of personal responsibility through the ascription of mental
illness. In other words, for the pragmatic theory to be coherent, it must be selective and
equipped to reject particular forms of behavior that are not best treated as medical
disorders, leaving them to other social institutions for appropriate management.

The recent rash of so-called sex addiction cases illustrates the difficult problem of
negotiating a proper balance when distinguishing between medical problems and social
or individual problems. Although sex addiction is not the DSM-IV, a broader category,
hypersexual disorder, is being considered for DSM-V. One proposed definition is the
following:

Over a period of at least six months, recurrent and intense sexual fantasies,
sexual urges, and sexual behavior in association with four or more of the
following five criteria: (1) A great deal of time is consumed by sexual
fantasies and urges, and by planning for and engaging in sexual behavior.
(2) Repetitively engaging in these sexual fantasies, urges, and behavior in
response to dysphoric mood states (e.g., anxiety, depression, boredom,
irritability). (3) Repetitively engaging in sexual fantasies, urges, and

behavior in response to stressful life events. (4) Repetitive but

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unsuccessful efforts to control or significantly reduce these sexual

fantasies, urges, and behavior. (5) Repetitively engaging in sexual

behavior while disregarding the risk for physical or emotional harm to self

or others.
The proposal stipulates that these criteria can be further specified by the way in which
they manifest. Examples offered include excessive masturbation, viewing of internet
pornography and repeatedly visiting strip clubs. Note that a consideration of the welfare
of other individuals is explicitly built into the defining symptoms of hypersexuality.
Additionally, part of the work group’s rationale for including hypersexual disorder is
popular demand: “There is a significant clinical need, even a ‘demand’ from mental
health consumers, for mental health providers to recognize and diagnose a distinct group
of men and women who have been seeking and are already receiving mental health care
such as individual psychotherapy, lZ-step group support, pharrnacotherapy, and
specialized residential treatments.” Indeed, as of late, famous movie stars, politicians,
and athletes, have committed themselves to rehabilitation regimes to correct or ameliorate
the “disorder” that ostensibly caused them to repeatedly commit adultery, call on
prostitutes, etc.

Proponents of its medicalization will point to reports that hypersexual behavior
has been Observed as a sequalae to various neurological disorders or injuries. For
example, there have been reports of hypersexual behavior resulting from strokes, which

were marked by an increase in libido, priapism (prolonged erection), and sexually deviant
behavior. 29 Another study has pointed to hypersexuality as a result of iatrogenic brain

lesions caused when placing intracranial shunts.3O Additional investigations on multiple

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sclerosis, Parkinson’s disease, epilepsy and other brain-based disorders such as Klr‘iver-

Bucy syndrome and dementia have uncovered instances of acquired hypersexuality

marked with paraphilia.31 In most of these cases hypersexual symptoms have been
correlated with temporal lobe disturbances or damage.

It is less clear that cases of idiopathic hypersexuality to be classified in the DSM-
V would be the result Of a discrete neurological injury. To the contrary, psychiatrists
have proposed a categorically different kind of hypersexuality that is not defined in terms
of biological injury or dysfunction. Rather its definition is explicitly normative and based
on a descriptive phenomenology of the behavior. For example, Stein, et a1. argue that
hypersexuality is culture-dependent:

...the judgment that the sexual fantasies, urges, or behaviors are excessive

(i.e., represent psychopathology) must take into account normal variation

as a function of age (e.g., in teenagers, high levels of preoccupation with

sexual fantasy may be normative) and subcultural values (e.g., in patients

who value celibacy, the presence of some sexual urges and associated

distress may be normative), as well as the degree to which the symptoms

are the source of distress or interfere with important areas of

functioning... the problem of delineating normal variation from

psychopathology is particularly difficult when, as in the case of

hypersexual disorder, the form of the phenomenology is (by definition)

normative. 32

The point here is not necessarily to be skeptical about hypersexual disorder as a

psychiatric category because of the nature of particular behaviors or the role of the free

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will in choosing to engage in those behaviors, but, rather, to first question whether
medicalizing them will have a broader positive outcome and to consider within that
calculation empirical evidence about the ways our understandings and expectations about
personal responsibility might be reshaped. As part of this tally, we might consider
slippery slope type ramifications for the expansion of mental disorder to include
hypersexuality: will the creation of an official category for hypersexuality lead to the
medicalization of other forms of sexual behaviors or habits? Will it reintroduce
problematic categories such as masturbation into the nosology, for example?

More substantively, we might consider the effects of an official appellation by
asking whether a diagnosis of hypersexuality will in fact reduce the risk and actual harm
caused by the individual against themselves, their spouses or lovers. Perhaps formalizing
the category of hypersexuality will open up promising avenues for treatment. Some might
argue that the ascription of mental disorder to habits associated hypersexuality will be in
fact helpful, because it will provide a more formal research structure from which we
might understand other forms of impulsivity and reckless behavior. Indeed, the DSM-V
work group cites this possibility as a rationale in its proposal.33 One final, albeit not
minor consideration, that is implicit in the reference to the demands of mental health
consumers and practitioners is that once hypersexuality is an official disorder, its
treatment can be paid for by insurance.

Additionally, anthropologists and sociologists have tracked the way in which
blame and mental illness are often mutually exclusive. Admonishment, blame and, to a
certain extent, stigma are significantly diminished by finding a biological basis (or mere

correlate) for a particularly problematic behavior. As T.M. Luhrmann offers, “Biology is .

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the great moral loophole of our age. . .a moral vision that treats the body as choiceless and

nonresponsible and the mind as choice-making and responsible has significant

consequences for a view of mental illness precariously perched between the two.”34 To
wit, the 100,000 member strong National Alliance for the Mentally Ill (NAMI) explicitly
contends that mental illnesses are completely somatically based and they espouse a ‘no-

fault’ policy, exculpating both patients and, in the case of mentally ill children, their

parents. 35 (This fact will become important in the following chapter as we explore the
way particularly powerful stakeholders influence psychiatric diagnoses.)

We should note that NAMI’s push to frame mental illness in terms of the
biomedical model of disease aims in part to minimize stigma suffered by the mentally ill.

But, as it turns out, research suggests that a biologically based concept of mental illness

might not reduce the amount of stigma at all.36 In fact, and somewhat surprisingly, the
“brain disease” narrative might have the opposite effect and actually increase stigma
because diseased individuals are considered to exist within a separate social category
altogether. In contrast those who are simply behaving badly continue to reside in the
mainstream and thus receive tacit acceptance despite the disruptions they might cause.
The point is that we must have an accurate accounting of costs and benefits before
haphazardly applying the biomedical model of disease to boundary cases simply because
our intuition tells us such an ascription will serve the best interests of people who are
suffering in some way that seems amenable to medical intervention.

To summarize, my goal here is not to render a clear verdict on the case of
hypersexuality, or other cases of potential pseudoillnesses, in relation to the question of

free will. Rather, my aim is to simply remind the reader that questions pertaining to vice

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and disorder should not be conflated with pragmatic assessments of how best to manage
problem behaviors. We see in the case of hypersexuality an illustration of the potential
risks and benefits of blaming as vicious or, alternatively, exculpating as disordered those
who engage in a particular set of sexual behaviors. Yet, from a pragmatic perspective,
the first question that needs to be answered is whether and how medical resources can or
should be brought to bear to minimize the suffering caused by'the sexual behavior of
“addicts.” If medical resources offer little or no benefit to sex addicts or to the
community then another social institution should address the behaviors associated with

sex addiction, if they are to be addressed at all.

Public Health & Personality Disorders

Part of my pragmatic theory will be to justify the inclusion of the behaviors of
concern as disorders within the psychiatric nosology on the grounds that they present a
public health risk. The ascription of mental disorder is the key that unlocks another
armamentarium of resources in public health, which can help minimize the suffering
caused by personality disorders. As Coid has argued, addressing the problem of

personality disorders through the public health model requires an approach that is rarely

if ever applied to them.” The public health problem-solving paradigm, as described by
Guyer, includes the following steps: (I) define the problem (2) measure the magnitude Of
the problem (3) develop a conceptual framework for key determinants of the problem,
including biological, epidemiological, sociocultural, economic and political determinants;
(4) identify and develop interventions and prevention strategies; (5) set priorities among

strategies and recommend policies; (6) implement programs and evaluate them. This

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framework will be helpful when we begin to think about policy ramifications of our

pragmatic theory of personality disorder. 38 Suffice it to say, each of these steps requires
additional research into the biological and sociocultural forces that combine to cause and
exacerbate personality disorders.

Nonetheless, there are presently enough data to make some general claims about
personality disorders as public health concerns; although compared with depression or
schizophrenia, there are not many epidemiological studies on personality disorders. Yet
in specific case of personality disorder, such as borderline, there are compelling data that
suggesting these disorders are both prevalent and costly. Moreover, public health
researchers are beginning to paint a picture of the increasing prevalence of personality
disorders (and their comorbidities such as depression) in the community. For example, in

1991, it was estimated, that the prevalence of borderline was as high as 1.8% of the

general population. 39 More recent data indicate that the prevalence of borderline to be

above six percent, though it should be acknowledged that these increases might in part be

an artifact of diagnostic drift.4O A 2006 study in the UK showed that the prevalence of

personality disorders, in general, to be 4.4% with Cluster B disorders as being especially

costly.41 In a recent metaanalysis, Eaton, et al. provide further evidence of their
prevalence. They indicate the prevalence of personality disorders to be nine percent, and
the enormous annual cost of treating personality disorders is estimated to be the hundreds
of billions of dollars. The indirect savings however in treating or preventing personality
disorder is difficult if not impossible to quantify at this point because of the dearth of
data. I will expand on these considerations in chapter 8 when I offer health policy

recommendations based on the pragmatic theory. The point here is that we can establish

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empirically that the constellations of behavior we are considering as disorders are
prevalent and costly.

A second question we might ask from a public health perspective is, “Are
personality disorders ‘contagious’ and do they pose a risk to the health of others in the
community?” If they do, this fact will amplify the costs of personality disorders and
provide additional justification for prevention and treatment of the disorders as well as
taking measures for the benefit of others who are at risk. As I suggested in the previous
section on the ends of medicine, personality disorders could be understood in terms of
their effects on others. As such, we can partially justify medical interventions for both
preventing and treating personality disorders not simply to treat the patient but to protect
the larger community from the effects of such disorders. Additionally, we can justify the
allocation Of medical resources to those who are directly affected by personality
disorders.

Although difficult to prove causation definitively—again because of a lack of
data—it is reasonable to argue from what we do know that personality disorders
contribute to depression, anxiety, and other common but debilitating mental illnesses in
the community, which are themselves “contagious” to a certain degree.42 Moreover, there
is a strong correlation between emotional or physical abuse of intimate partners, spouses
or children and personality disorders.43 For those in relationships with people with
personality disorders, we see an increased likelihood of depression, anxiety and other
mental illnesses.

To further illustrate how public health perspective supports a pragmatic theory of

mental disorder, consider analogous cases in which public health measures have had a

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profound impact on improving health outcomes. For example, I cite efforts to maintain
safe drinking water, eliminating toxins from food, public health campaigns to decrease
the prevalence of tobacco use, or vaccination efforts. In each case, social and medical
resources are deployed in a large-scale fashion to both prevent and minimize the effects
of the target problem.

One key difference is that in the standard cases of public health intervention that I
mention, the target is an entity that exists independently from the public risk it poses.
Small pox is a disease caused by the variola virus, whether it affects one person or
spreads to 1000 people. The fact that small pox is easily transmissible is not part of the
explanation Of its existence; rather it is a secondary characteristic of the disease. In the
case of personality disorder, however, the ontological story is different. What I am
arguing is that the risk posed to the public health is actually one constitutive element of
the nosology that includes personality disorders. This is particularly the case with Cluster
B disorders, which are marked by socially dysfunctional behaviors and which have a
direct negative impact on others. Simply put, in the case of a pathogen we are talking
about natural kinds. In the case of personality disorders we are talking about artificial or
pragmatic kinds that are defined, in part, by their pernicious impact on others. So,
admittedly, the comparison to viral contagious is logically problematic.

Notwithstanding this disanalogy, we can utilize the public health model to help
address the costs and risks that personality disorders in fact do present to the broader
community. Therefore, when we consider the evidence of the broad social and economic
impact of mental illness, it seems reasonable to suggest that specific instances of mental

illness such as personality disorders should be viewed in much the same way as other

129

public health problems. Again, this issue will be taken up in further detail in the chapter
on policy. For now, it is important to understand that the potential of the public health

model in mitigating the effects of personality disorders represents yet another facet in

their being considered medical problems.

Conclusion

The goal of this chapter was to begin to describe what a pragmatic theory of
mental disorder will look like. As I described, such a theory requires we situate its
target—constellations of behavior of concern—within the broader context of medicine, as
we also must adequately define them. To do this, I argued that a personality disorders
seem to cause a form of suffering that intersects with the traditional ends of medicine. I
also cross-analyzed these behaviors with the concept of habits from pragmatic
philosophers to more clearly mark out the kinds of behavioral units to which the
comprehensive theory should address. I also attempted to show how the pragmatic
theory would address the common question of whether the habits or behaviors in question
would more appropriately be considered instances not of mental disorder but of vice.

Here we saw the pragmatic shift toward assessing the consequences and empirical

realities of ascriptions of mental disorder as the key to deciding what is an otherwise
irrelevant distinction. In the next chapter, I will continue to expand on my proposed
comprehensive pragmatic theory by describing the key ethical subtheories, which I

believe should be used to guide its application to particular disorders.

1. American Psychiatric Association, "Definition of a Mental Disorder"

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=465 (accessed February 11,
2010).

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2. “Laura” is from Paul T. Mason and Randi Kreger, Stop Walking On Eggshells 2nd ed
(Oakland, CA: New Harbinger Publications, 2010), 65, 97, 54, respectively; “Anthony” is from Anthony
Walker, The Courtship Dance of the Borderline (San Jose, CA: Writer's Showcase, 2001); reprinted in
Nancy Nyquist Potter, Mapping the Edges and the In-Between, (New York: Oxford University Press,
2009), 47.

3. Mary C. Zanarini, Frances R. F rankenburg, Christine J. DeLuca, John Hennen, Gagan S. Khera,
and John G. Gunderson, “The Pain of Being Borderline: Dysphoric States Specific to Borderline
Personality Disorder,” Harvard Review of Psychiatry 6, no. 4 (1998): 201-207.

4. Arthur Kleinman and Joan Kleinman, “The Appeal of Experience; the Dismay of Images:
Cultural Appropriations of Suffering in Our Times,” in Social Suflering, ed. Arthur Kleinman, Veena Das,
and Margaret M. Lock (Berkeley, CA: University of California Press, 1997), 2.

5. It should be noted that some mental health professionals view road rage as a sign of a deeper
disorder (Intermittent Explosive Disorder) that is worthy of treatment.

6. Admittedly, this assertion is controversial. Some argue that SSRI’s are nothing more than active
placebos. See, for example, Irving Kirsch, The Emporer 's New Drugs: Exploding the Antidepressant Myth
(New York: Basic Books, 2010).

7. C. Ben Mitchell, Edmund D. Pellegrino, Jean Bethke Elshtain, John Frederic Kilner and Scott
B. Rae, Biotechnology and the Human Good. (Washington, DC: Georgetown University Press, 2007, 121.

8. Edmund D. Pellegrino, "The Goals and Ends of Medicine: How Are They to be Defined?" in
Physician and Philosopher ~—— The Philosophical Foundation of Medicine: Essays by Dr. Edmund

Pellegrino, ed. Roger J. Bulger and John P. McGovern, (Charlottesville, VA: Carden Jennings Publishing,
2001), 62.

9. lbid., 63.

10. William James, Principles of Psychology. (New York: Henry Holt & Company, 1890).

I I. William James, Psychology: American Science Series, Briefer Course. (New York: Henry
Holt & Company, 1915), 134.

12. lbid., 135.

13. lbid., 144-145.

14. John Dewey, Human Nature and C onduct: An Introduction to Social Psychology. (New York:
Henry Holt & Company, 1922), 42.

15. lbid., 25.

16. Gordon Willard Allport, “Dewey's Individual and Social Psychology,” in The Philomphy of
John Dewey, Vol. 1, ed. John J. McDermott, (Chicago: University of Chicago Press, 1981), 272.

17. Ibid, 21.

18. Klaus Lieb, Mary C. Zanarini, Christian Schmahl, Marsha M. Linehan, and Martin Bohus,
“Borderline Personality Disorder,” The Lancet. 364, no. 9432 (2004): 453-461. As Lieb, et al. point out,
“Data for the role of genetic factors are sparse. In one twin study, based on DSM-IV criteria, concordance
rates were seen for borderline personality disorder of 35% and 7% inn monozygotic and dizygotic twin
pairs, respectively, suggesting a strong genetic effect in the development of the disorder.” (454)

I9. Immanuel Kant, Anthropology from a Pragmatic Point of View, ed. Robert B. Louden (New
York: Cambridge University Press, 2006), 7:198.

20. Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason. (New
York: Random House, Inc., 1965).

21 . William Tucker, “The ‘Mad’ vs. the ‘Bad’ Revisited: Managing Predatory Behavior,”
Psychiatric Quarterly 70, no. 3 (1999): 221-230.

22. 1 should note that such pragmatic shift seems to have occurred in the framing of such concepts
as psychopathy and sociopathy. These terms are found in the controversial definition of antisocial
personality disorder through the DSM-II through DSM lV-TR. They are often associated with criminal
behavior. Within these volumes the term psychopathy has been used as both a symptom of severe mental
disorder and is now considered to be a validated metadisorder, which is characterized by an amalgam of

symptoms of various personality disorders. Robert Hare’s work in composing his multi-volume Hare
Psychopathy Checklist has been used to assess and diagnose psychopathy and criminality. It also offers a
predictor of recidivism. Recently, the Checklist has met with critique and controversy. See: Jennifer L.
Skeem and David J. Cooke, “Is criminal behavior a central component of psychOpathy? Conceptual
directions for resolving the debate,” Psychological Assessment 22, no. 2 (Jun. 20 I 0): 446-54.

131

 

23. William James, “The Dilemma of Determinism,” in The Will to Believe and Other Essays in
Popular Philosophy. (London: Longrnans, Green, & Co., 1921), 328-340.
24. William James, Pragmatism: A New Name for Same Old Ways of Thinking, London:
Longmans, Green, & Co., 1909, 118.
25. lbid. 119.
26. lbid., 116.

27. Harold W. Koenigsberg and Larry J. Siever, “The Frustrating No-Man’s-Land of Borderline
Personality Disorder.” Cerebrum Fall, 2001, http://www.dana.org/news/cerebrum/detail.aspx?id=3372
(Accessed April 5, 2010).

28. Theodore Millon and Seth Grossman, Moderating Severe Personality Disorders: A
Personalized Psychotherapy Approach (New York: Wiley, 2007), 234.

29. TN. Monga, M. Monga, M. Raina, and M. Hardjasudarma, “Hypersexuality in Stroke.”
Archives of Physical Medicine and Rehabilitation. 67, no. 6 (1986): 415-417.

30. David G. Gorman and Jeffrey L. Cummings, “Hypersexuality Following Septal Injury”
Archives of Neurology 49, no. 3 (1992): 308-310.

31. Elliot M. Frohman, Teresa C. Frohman, and Ann M. Moreault, “Acquired Sexual Paraphilia in
Patients With Multiple Sclerosis,” Archives of Neurology 59 (Jun. 2002): 1006-1010.

32. Dan J. Stein, Donald W. Black, Nathan A. Shapira, and Robert L. Spitzer, “Hypersexual
Disorder and Preoccupation With Internet Pornography,” American Journal of Psychiatry 158, no. 10
(2001): 1593.

33. “Research Need. There is a significant research-associated need to consolidate an operational
definition for such a condition so that research from varying theoretical perspectives can coalesce with a
common set of criteria. Such a condition has been clinically described for over 200 years in Western
cultures (by authors including Benjamin Rush, MD, one of the Founding Fathers of the USA), but a
specific empirically supported and polythetic set of operationalized criteria, as proposed here for DSM-V,
has not been validated. In the 10th edition of lntemational C lassifrcation of Diseases, ‘excessive sexual
desire’ is noted but without any suggested operational criteria. A DSM-V sexual disorder associated with
marked and persistent increased normophilic sexual behaviors with adverse consequences would be
consistent with the aforementioned codified diagnosis. A DSM-V-based empirically derived definition
should significantly enhance research efforts to explore some of the additional diagnostic validators for
which there are no current data.” from

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=4l5# (Accessed March 24,
2010).

34. T.M. Luhrmann, Of Two Minds: An Anthropologist Looks at American Psychiatry (New York:
Random House, 2000), 8.

35. On their organization’s “About” webpage, for example, NAMI states: “NAMl's support and
public education efforts are focused on educating America about mental illness, offering resources to those
in need, and insisting that mental illness become a high national priority. Mental illness is a serious medical
illness that affects one in four families. No one is to blame. Treatment works, but only half of people living
with mental illness receive treatment. NAMI has engaged in a variety of activities to create awareness
about mental illness and promote the promise of recovery.”

http://www.nami.org/Content/N avigationMenu/lnform_Yourself/About__NAMI/About_NAMI.htm
(Accessed April 13, 2010).
36. Sheila Mehta and Amerigo Farina, “ls Being ‘Sick’ Really Better? Effect of the Disease View
of Mental Disorder on Stigma,” Journal of Social & Clinical Psychologv 16, no. 4 (1997): 405-419.
37. Jeremy Coid, “Epidemiology, Public Health and the Problem of Personality Disorder,” British
Journal of Psychiatry 182, suppl.44 (2003):s3-10.
38. Bernard Guyer, I998. “Problem-solving in Public Health,” in Epidemiology and Health
Services, ed. Haroutune K. Armenian and Sam Shapiro (NewYork: Oxford University Press, 1998), As
cited by Coid, 2003, 53-10 (see n. 35).
39. Thomas A. Widiger and Myrna M. Weissman, “Epidemiology of Borderline Personality
Disorder,” Hospital & Community Psychiatry 42» (001- 1990:1015-1021-
40. Raz Gross, Mark Olfson, Marc Gameroff, Steven Shea, Adriana Feder, Milton Fuentes.
Rafael Lantigua, and Myrna M. Weissman, “Borderline Personality Disorder in Primary Care,” Archives of
Internal Medicine 162 (2002):53-60.

132

 

41. Jeremy Coid and Min Yang, “Prevalance and Correlates of Personality Disorder in Great

Britain,” The British Journal of Psychiatry 188 (2006):423-431 .
42. T.E. Joiner, Jr., “Contagious Depression: Existence, Specificity to Depressed Symptoms, and

the Role of Reassurance Seeking,” Journal of Personality and Social Psychology. 67, no. 2(1994): 28 7-

296.
43. Donald G. Dutton, The Abusive Personality, (New York: The Guilford Press, 2007).; Daniel

W. Edwards, Charles L. Scott, Richard M. Yarvis, Cheryl L. Paizis, and Matthew S. Panizzon,
“lmpulsiveness, Impulsive Aggression, Personality Disorder, and Spousal Violence,” Violence and Victims

18, no.1 (2003):3-14.

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CHAPTER 5

PRAGMATIC ASCRIPTIONS OF PERSONALITY DISORDERS: ETHICAL SUBTHEORIES

Introduction: Anticipating Objections

Let us now Shift to more specific ethical questions that emerge from a pragmatic

Banja, pragmatic theories Of disease, whether mental or physical, are both evaluative and
descriptive. The evaluative component of the theory is what needs to be explicitly
examined for the theory to be truly ethically defensible. Once we accept the reality that
boundary cases of mental illness such as personality disorder are impossible to define in
strictly naturalistic terms, we must begin to ask how and why they are defined. And as we
now know, the criteria for personality disorders are by definition culturally dependent
and implicitly pragmatic. Therefore, a careful examination of the motivation for deeming
some behaviors as being socially dysfimctional is of central importance if we are to claim
our pragmatic theory meets ethical muster. Otherwise, one could imagine a pragmatic
theory that encompasses or ignores instances of potential mental disorders according the
expeditious whims of the social group in power, the paucity of available resources,
current medical diagnostic fads, or as a result of disease mongering efforts by powerful
economic stakeholders. Thus, the set of ethical subtheories or considerations presented in

this chapter aims to create a set of ethical parameters within which pragmatic ascriptions

- I
of mental disorder should occur.
Each ethical subtheory will also aim to head Off at the pass several anticipated
Objections and concerns that might be voiced about pragmatic categorizatrons of

behaviors. These objections have their roots in those objections we have already seen In

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response to naturalistic nosologies by strong normativists. From this side, there are those
that argue the medicalization of personality types as ‘disorders’ is simply a social control
scheme. Some of those who posit this objection, the so-called anti-psychiatrists, as we
now know, reject even core cases of mental illness as nothing more than mythology
engineered to enhance and expand prevailing power structures. It is therefore reasonable
to expect that this objection would be vigorously raised against our overtly pragmatic
theory for personality disorders. In considering personality disorders, for example,
Szasz, not surprisingly, states:

We are proud that we do not punish acts or beliefs that upset others, but do

not injure them and hence do not constitute crimes. Yet, we punish

people—albeit we call it “treatment”—-for annoying family members (and

others) with behaviors they deem “dangerous” and also for “being

suicidal.” To be sure, persons who exhibit such behaviors—labeled

“schizophrenics,” “persons with dangerous severe personality disorders,”

and “suicidal patients”———frighten others, especially those who must

associate with them. Unable to control non-criminal “offenses” by means

of criminal law sanctions, how can the offended persons and society

protect themselves from their unwanted fellow men and women?2
Although he (probably intentionally) confounds core cases of mental illness with
boundary cases of disorder, Szasz’s worry is that the ever-expanding role of psychiatry,
through the development of ideals of normal personality, will continue to intrude into the

lives of those who should otherwise be considered eccentric, quirky or simply unique.

135

Szasz’s worry is a libertarian one, which reflects his more basic phiIOSOphical
commitment to strong psychiatric nihilism and the simple idea that individual liberty is
constrained by the medicalization of the free choices of individuals. Conversely, this
argument has also been deployed across controversies related to legal responsibility and
forensics more generally. The standard Szaszian-libertarian objection to the insanity
plea, for example, is based on the argument that psychiatry is itself a branch of the justice
system and as such it is simply another form of social control. Szasz makes this point in a
1996 debate on the question, “Should the Insanity Defense be Abolished?”:

But let me add one other thing, which is absolutely essential: that I not

only do not believe mental illness is an illness, I also do not believe that

people who have not committed any crime should be deprived of liberty. I

believe that the term "mental hospitalization" is an ugly, political term for

incarcerating innocent people who are depressed, who are anxious, who

complain about something, who have not done anything which is against

the law. And this is what psychiatry is based on. The insanity defense and

civil commitment are like Siamese twins. You cannot abolish one without

killing the other.3
We can therefore predict one set of objections that would inevitably emerge against my
proposed use of pragmatism to justify the ascription of mental disorder. It is, quite
honestly, tempting to sideline these objections as being simply radical and extreme
instances of the ravings of anti-psychiatry paranoia. However, we must take seriously
these objections insofar as they forewam the overreach of psychiatric labels and a shift

away from personal responsibility toward what sociologist Peter Conrad has called “the

136

problem of expert control”—-—a dynamic defined in part by the intrusion of medical

professionals who are given license to address problems of everyday life.4 I nonetheless
acknowledge that it will be a more-or-less impossible task to offer an ethical framework
to fully justify my pragmatic theory to strong anti—psychiatry libertarians like Szasz. But
by offering several ethical subtheories to reasonably constrain the pragmatics of
psychiatric ascriptions, I Shall hopefully allay some of the concerns of more moderate
libertarians.

While the libertarian objection about the ascription of mental disorder might be
considered a substantive objection to the basic foundations of psychiatric nosology,
another set of anticipated objections would focus on the procedural aspects of the
pragmatic diagnosis and classification processes. In other words, this latter set Of
objections would not be concerned with the pragmatic concept of mental disorder per se.
Rather, procedural objections to pragmatic ascriptions of mental disorder would be
Specifically concerned about “getting it right.” This is to say, the concerns of those who
think that mental disorders reflect particular social biases, enhance or reinforce social
controls, or covertly disenfranchise groups of individuals will demand that all pragmatic
ascriptions of mental disorder pass several ethical litmus tests. These procedural concerns
are what my ethical subtheories primarily aim to answer.

Let me begin with a description of what I take to be the foundational requirements
needed for my pragmatic theory to be ethically applied. These foundational requirements
are themselves rooted in virtue theory, which sets out key expectations that individual
mental health professionals should meet. I will primarily be building off of Nancy

Potter’s work here. In her recent feminist philosophical investigation into the etiology

137

and treatment of borderline personality disorder, Potter has described several of the

virtues I wish to highlight.5 To Potter’s lights, these virtues include trustworthiness,
empathy, and the competency to engage in a special form of listening called ‘uptake.’ 1
will add a few virtues of my own to round out Potter’s set. I will describe each of these
and bundle them together into a broader pragmatic principle of beneficence.

After describing the virtues of individual clinicians, I will present the key ethical
subtheories needed for a pragmatic nosology to be ethically applied at the macrOSCOpic
levels of diagnostic classification and health policy. These ethical touchstones will frame
out the way in which DSM work groups, for example, should engage in thoughtful and
critical reflection about the broader social and political biases that might inform their own
work. In particular, procedural checks will be recommended in order to limit the
influence of potentially pernicious or ethically dubious motivations driving the addition
or deletion of mental disorders from the official nosology. In the next chapter, we will see
how these subtheories become critical to implementing a pragmatic nosological analysis

of borderline personality disorder.

Virtues of Individual Practitioners

In developing the comprehensive pragmatic theory, I emphasized the need for
particular theoretical checks on the expansiveness of how the theory would be applied.
Recall that a central motivation for including personality disorders within the domain of
medicine was that medicine is equipped to relieve or minimize the suffering that is often
associated with instances of personality disorders. For the pragmatic theory to be

successful, it is crucial that it is implemented ethically and that those who directly

138

interface with patients—mental health practitioners-«have insight and understanding
about their role both as diagnosticians and caregivers. The imprimatur of an official
diagnosis—one that only can be made by medical professionals—entails that medical
professionals remain cognizant of both their power and responsibilities in their use of
these diagnoses. While such sensitivity is important for all aspects of medicine, it is
especially important in cases of boundary cases of mental illness, where the application
of a diagnosis of personality disorder—defined according to pragmatic considerations——
carries with it an array of political and social risks. In contrast, it is arguably the case that
in oncology, infectious disease, or core cases of mental illness—that is, in clearer cases of
disease and illness—the act of diagnosis will be less ethically fraught than in cases of
personality disorder. This simply is because diagnoses in those cases are can be made
according to a clearly naturalistic conceptualization of disease and illness.

As a reminder, naturalistic nosology provides a solid grounding for understanding
and justifying the claim that a particular biological dysfunction (defined by atypical
function) is a disease; those dysfunctions that have a negative impact on human
flourishing are illnesses. When dealing with diagnoses of boundary cases, which I have
argued should be brought into the nosology for pragmatic reasons, mental health
practitioners Should be expected to understand how their act of diagnosis differs ethically
from diagnoses made in cases that fall more Obviously within the domain of naturalistic
theories of disease. We should therefore expect mental health practitioners’ core set of
professional skills to include several unique virtues. In discussing the ideal set of virtues
of clinicians who treat borderline personality disorder, Nancy Potter makes this very

point: “The aim of psychiatric treatment both medical and psychological is to restore

139

some autonomy, self—worth, and humanity to the mentally ill. When thinking about
flourishing, then, I am including the need for clinicians to grow in virtue and self-

reflection as better to work with their BPD patients and bring them a degree of

flourishing in their lives.”6 In fact, we can look to Potter’s work on the distinctive virtues
required of clinicians who work with borderline personality disorder to serve as the
foundation for our set of ethical theories complement our pragmatic theory.

As we already know, virtues represent the mean between two extremes of a
particular property of character. Similarly, Potter emphasizes the Aristotelian point that
virtues are not simply a set of character traits that provide a person the intellectual and
moral guidance for right or good action. Virtues are also internal states of character that,

as Phillipa Foot argues, manifest as actions. Virtues are, thus, expressions of “will that is

good.”7 For Aristotle, Foot, Potter, and other virtue theorists, the teleological orientation
of virtue theory is similar to our pragmatic theory in that, despite the moniker of ‘theory’,
it is actually atheoretical; virtue theory prioritizes particularity and real action over

intellectual appeals to abstract principles or categorical rules.

Beneficence

In contemporary bioethics, claims that invoke principles, which, in turn, justify
directives about the duties or Obligations of physicians, have largely supplanted ethical
arguments based on virtue at least in clinical contexts. By now it is well known that the
principle of beneficence, as described most famously by Beauchamp and Childress,
encompasses the duties and Obligations that a physician has toward her patients.

Depending on which edition of Beauchamp and Childress’s Principles of Biomedical

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Ethics one reviews, the principle of beneficence applies to cases as a moral benchmark
and action guide (1St edition) or as a bipartite principle that encompasses hard and soft
kinds (6’h edition). Although now is not the time to critique Beauchamp and Childress’s
four principles—there is plenty of critical literature available elsewhere—it is important
to note their conceptual shift from an obligation-based principle of beneficence toward a
more holistic version, which integrates, or at least invokes, substantial philosophical
insights from virtue theory.

I wish to adopt a version of this more holistic principle of beneficence to ground
the first ethical subtheory of the pragmatic theory of mental disorder. Beneficence will
also serve as a theoretical touchstone as we move through other ethical dimensions of the
pragmatic theory. TO say that beneficence is a foundation of the pragmatic theory is
simply to say, for our pragmatic theory to be ethically defensible evaluations of social
function or dysfunction Should be primarily motivated by the authentically beneficent
goal of caring for people who are suffering. I‘should be careful to also note that
reference to this principle should not be interpreted as an endorsement of specific set of
hard and fast obligations, as is sometimes the classical Hippocratic interpretation.

Rather, as Dewey claims, “a moral principle. . .is not a command to act or forbear
acting in a given way: it is a tool for analyzing a special situation, the right or wrong
being determined by the situation in its entirety, and not by the rule as such.”8 Thus, the
principle I am proposing of authentic beneficence should be thought of less as a
theoretical principle and more of a meta-virtue that is derived from a person’s capacity
for honesty, compassion, and empathy for example. As such, it must be present or

cultivated among practitioners who are engaged in the important tasks of diagnosing and

141

treating mental disorders. We can therefore begin to see another very practical dimension
of our theory—its success depends on the actual character of those involved in its
implementation and application.

Let us therefore envision attaching to the artifice of the pragmatic theory a set of
virtue subtheories bundled together into a pragmatic principle of beneficence. This will
be our initial step in building the comprehensive pragmatic theory. To do this, we can
again look to theoreticians such as Pellegrino who posit beneficence to be the
overarching principle of medical ethics, because it is internal to the practice of medicine.
And again, we might adapt his theoretical perspective to fit our pragmatic need: to ensure
the ethical application of the ascription of mental disorder requires individual clinicians
to be motivated by genuine concern and care for the patient. We can see how
beneficence is built upon several more fundamental virtues, such as trustworthiness,
compassion, and integrity. Each of these virtues provides clinicians a set of ethical skills
to apply the pragmatic theory across all of their key professional tasks: properly
recognizing and diagnosing personality disorders and skillfully treating those disorders.

The first critical juncture in the ethical application of the theory is in the
recognition and appropriate diagnosis of a personality disorder. This task is distinct from
the subsequent treatment phase, which requires its own set of allied virtues. Therefore, it
is important to note that, although the following virtues permeate the entire clinical
encounter, they will Shift in importance across the more specific junctures of the
encounter. For example, as we will see in the following chapters, the Skill to integrate
theoretical knowledge of the norms and values implicit in the borderline label will prove

most useful during initial meetings with a female client. Certainly, as I will Show,

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remaining cognizant of these dimensions of the disorder will be critical during the
treatment phase, should the patient be diagnosed with the disorder. But on intake, the
clinician should have the reflective capacity and prudence to quickly and precisely
triangulate between the clinical, sociopolitical, and ethical dimensions of making an
actual diagnosis.

Let us now dissect the broader principle of beneficence by discussing several of
the key virtues necessary for mental health providers to work with beneficence within a
pragmatically constructed nosology of mental disorders. What follows is by no means an
exhaustive list. Rather, these virtues seem to me to be necessary, although not sufficient,
skills that clinicians who are entrusted with the power of pragmatic ascriptions of mental

disorder should possess.

Trustworthiness in Diagnosis & Treatment

Trustworthiness is a foundational concept described by Potter in her detailed list
of virtues She endorses for mental health clinicians. She inventories the dimensions of
trustworthiness as she builds a case for applying her virtue theory to treating borderline
personality disorder. For our purposes, we will look at trustworthiness as a core virtue in
the application Of our pragmatic theory of personality disorders and adapt several of her
key points accordingly. We will first look at how trustworthiness is crucial to the task of
treating persons with mental disorders. Trustworthiness should be defined not simply as
the moral capacity for individual clinicians to be trusted with information and with
patient care and welfare. For example, mental health clinicians are not simply empty

vaults to be used by clients or patients who entrust them with their darkest thoughts or

143

most vulnerable feelings during treatment. The importance of this somewhat passive form
of trustworthiness, it seems, should be obviOus.

When understood more accurately as an “active” virtue, however, trustworthiness
can be thought of as a skill that provides clinicians the wherewithal to not only act as a
genuinely loyal caregiver, but also to act appropriately within the complex milieu of
clinical psychiatry. This complexity is especially heightened when working with patients
who suffer from personality disorders. In this context, Potter argues that “epistemic
responsibility” must be taken seriously. What she means here is that not only should
clinicians cultivate their more “passive dependability but [also] an active engagement

with self and others in knowing and making known one’s interests, values, moral beliefs,

and positionality.”9 This skill is a key to managing appropriately the dual conflicts that

often emerge from relationships with patients suffering from personality disorders. As

Potter points out:
Fostering and sustaining trust is recognized as vital to the therapeutic
relationship, and sustaining trust requires one to straddle an awkward
midlevel position between being trustworthy to one’s patient and being
trustworthy to one’s clinic, one’s colleagues, and the psychiatric industry.
Still, this in-betweenness of positionalities of power calls for maintaining
trustworthiness toward one’s patients and openly acknowledging the
compromised position one occupies.10

As we will see in our case study on borderline in chapters 6 and 7, many of the ethical

subtheories at work within the pragmatic theory aim to ensure that power relations are not

exploited or enhanced. In both diagnosing and treating personality disorders especially,

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the pragmatic psychiatrist must be trusted to be keenly aware of the particular
vulnerabilities of the patient and resist the temptation, as is so often the case with
therapists of borderlines, to deem them incurable or unmanageable. Such a move would
be a breach of trust insofar as it would fail to provide the patient with what the patient
had expected—a breach that would compromise the overall pragmatic model we are
attempting to strengthen.

In a certain sense, the untrustworthy clinician is an incompetent clinician because
she is more apt to misapply and misapprehend the gravity of psychiatric diagnosis and
treatment. This brings us to the second dimension of trustworthiness, which actually is
occurs prior to treatment: trustworthiness is crucial for proper diagnosis. The trustworthy
diagnostician is skilled in his ability to apply the label of disorder responsibly,
recognizing consequences of that label to the patient and other stakeholders. A better
way to understand the importance of trustworthiness in diagnosis is to consider what its
deficiency might cause. A failure of trustworthiness would fatally undercut our larger
project of treating personality disorders as illnesses for pragmatic reasons. The virtue of
trustworthiness is essential because without clinicians who are trustworthy, the first step
in implementing the pragmatic theory—that is, appropriately recognizing problem
behaviors, diagnosing them as mental disorders and working to relieve suffering—will
prove unfeasible. This is the case for the commonsense reason that an untrustworthy
clinician will at best engender little confidence and at worst suspicion and outright
rejection by their clients or society at large, causing those pragmatically defined

diagnostic categories to collapse under the weight of skepticism.

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Already we know that the risk of this happening is more plausible for boundary
cases of mental illness than for, say, cases of somatic illnesses like cancer or infectious
disease. Granted, somatic diagnoses have been misused for ethically dubious ends; one
need only think of how in the 1980’s HIV/AIDS provided particular stakeholders with
the stalking horse needed to push particular moral agendas in the name of health and
safety. In these cases, however, the misuse of the diagnosis was a side effect of the
diagnosis itself. When a patient was diagnosed with HIV/AIDS a set of moral and
religious claims were deployed to cast judgments about the cause of disease contraction.
Thus, these were judgmental overlays about of the causes of the illness and. such
judgments were not constitutive of the diagnosis itself.

In contrast, the very nature of the diagnoses of boundary cases in mental health
makes the potential for abusive practices significantly greater because such abuses will be
embedded in the definition of the disorder itself. For example, when a pragmatic
ascription of mental disorder is abused or misused, the actual diagnoses and their related
symptoms include the abusive assumptions. This point will become clearer as I describe
additional ethical subtheories and illustrative cases. We shall see in historical examples
how public trust was misused or squandered in the name of social control, profit,
gendered power structures or medical-moral brinksmanship. For now, to be clear, what I
simply propose is that a robust concept of trustworthiness can stand as a bulwark against
various sorts of abuses that are possible with pragmatic ascriptions of mental disorder.

Some will argue that the ideal of trustworthiness sketched above is simply
impossible to achieve and it is unlikely that pragmatic ascriptions of mental disorder can

happen without some amount of abuse of misuse. In setting out the larger pragmatic

146

principle of beneficence, instantiated here by an ideal of trustworthiness, as a necessary
ethical standard by which clinicians should make pragmatic ascriptions of diagnosis, we
set ourselves up for inevitable failure because such a standard it is patently unrealistic and
it creates standards that are unachievable. Moreover, opponents might also argue that
such ideals render the pragmatic theory anything but pragmatic.

At first glance, this objection seems reasonable. After all, how can our pragmatic
theory be expected to succeed if it, in turn, relies on a set of ethical standards that are
both unrealistic and unachievable? However, this objection fundamentally misses the
mark on exactly what I am proposing in setting out this ethical subtheory in particular
and the entire set of subtheories more generally. Trustworthiness is not a transcendental
ideal. It is not a quality that should be measured against a standard of perfection. Rather,
trustworthiness is a particular moral skill that might be achieved in various degrees by
individual clinicians. By projecting onto my proposal an expectation of perfection, the
objection implicitly concludes that my proposal is one that is based on the moral principle
of veracity instead of the virtue of trustworthiness.

This implication is of course incorrect. By proposing the virtue of trustworthiness
as the basis for our first ethical subtheory, we build into that that theory some room for
error. There is no expectation that every individual clinician would in fact be trustworthy.
This is an unfortunate but inevitable reality. Rather, what the subtheory proposes is that
there should be a critical mass of trustworthy clinicians, who can provide enough
confidence in the overall system of pragmatic diagnosis and treatment, and police
themselves to sanction clinicians who are not trustworthy. Achieving this critical mass

will require policy mechanisms and pedagogical improvements, for example. Moreover,

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achieving such a level of trust will require our next virtue, which is closely allied with
trustworthiness. The capacities for moral insight will provide clinicians the skill to both
understand their own motivations and act with integrity in making transparent these

motivations.

Insight in Diagnosis

In addition to being trustworthy, a clinician who is authentically beneficent
possesses two well-developed and complementary capacities: the ability to be self-aware
and the will to engage in ongoing self-reflection. These key capacities will help the
practitioner remain cognizant of their own biases—whether they are scientific,
philosophical, social, or political. The importance of these capacities among individual
mental health providers cannot be overstated because the diagnosis of a mental disorder
is a profound ethical choice. In addition to having the ethical dimensions of any medical
diagnosis, psychiatric diagnoses are particularly ethically fraught. They involve weighing
what are often significant costs and benefits to the patient; it includes the determination
of how best to manage medically——and possibly coercively—the behaviors of a person
who is in some way rendered vulnerable to the powers of the institutions of medicine and
the state. Thus, to reiterate, diagnosis in psychiatry must be done especially carefully.

As Reich argues, “It is the prerogative to diagnose that enables psychiatrists to
commit patients against their wills, that delineates the populations subjected to their care,

and that sets in motion the methods they will use for treatment. And it is therefore this

prerogative that should provoke perhaps the most fundamental—and, consequently, the

most serious—~ethical examination?“ All of the ethical problems—the biases and

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misapplications—of psychiatry more generally, which we will encounter in the following
case studies, boil down to individual acts of diagnosis. It is in the action of labeling
individual patients that nosological categories are brought to life, one patient at a time.
Moreover, a misapplication of psychiatric diagnoses becomes tempting for all
sorts of nonmedical reasons. Reich argues that psychiatric diagnosis is particularly
seductive because it possesses a “fetching beauty” and transforms “the fright of chaos
into the comfort of the known; the burden of doubt into the pleasure of certainty; the
shame of hurting others into the pride of helping them; and the dilemma of moral
judgment into the clarity of medical truth. [Djiagnoses can do such things in efficient and
powerful ways; and the fact that they can makes their use by psychiatrists for such ends
remarkably irresistible, enormously unrecognizable, and, in the final analysis, utterly
human.” '2 The ethical dimensions of discrete acts of diagnosing a patient as mentally ill
have broader significance when we consider the overall human enterprise of psychiatric
classification. A comprehensive pragmatic theory of mental illness must therefore offer
guidance to the professionals—such as DSM work group members—who are involved in
developing or refining classification schema. The virtue of insight will empower

clinicians to critically reflect on their use of pragmatic diagnoses, particularly their

motivations, and how those motivations are in or out of synch with the needs of patients.

U take Em ath & ‘World-Traveling’ in Treatment

Related to the virtue of insight are the concepts of uptake and empathy, which are

 

central to Potter’s analysis. These concepts will round out our list of core virtues of
clinicians who work with patients suffering from personality disorders. Essentially the

capacity for uptake will enable clinicians to firlly engage empathically with the patient in

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her time of distress while simultaneously maintaining a safe clinical distance, which is
crucial in cases of personality disorders such as borderline. For our purpose, this virtue
will aid in assuring the ethical application of a pragmatic ascription of disorder to
constellations of behavior that are deemed dysfunctional because it will shift the
descriptive weight of the ascription to the patient herself. By this I mean that a clinician
will not project onto the patient expectation about how or why she is behaving in ways
that cause her suffering. Rather the clinician skilled at uptake will inspire a conversation
about the nature of the patient’s suffering to “come off” in a way that enables the patient
to fully describe the set of behaviors and accept that they are the source of chronic mental
or emotional anguish.

Potter explicates this virtue in terms of basic concepts in philosophy of language.
According to J .L. Austin, speech acts are a particular kind of action that require a
particular form of acknowledgment of the listener for the action to ‘come off’. In the case
of making a verbal promise, for example, Austin argues that for such an act to hit its
mark, the speaker places himself or herself under an obligation to the listener who must
likewise provide recognition of the promise. In the context of anger often encountered in
cases of borderline disorder, Potter refers to Marilyn F rye’s application of Austin’s
philosophy. Frye states, “being angry at someone is somewhat like a speech act in that it

has a certain conventional force whereby it sets people up in a certain sort of orientation

to each other; and like a speech act, it cannot ‘come off‘ if it does not get uptake.”l3

Potter points out that uptake is required for therapists to fully understand a borderline
patient’s angry behavior; otherwise it is tempting for the therapist to simply cast the

behavior in terms of petulant childish behavior or primitive defensiveness without

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attending to the actual circumstances that may in fact give rise to the behavior. Indeed, as
we know from our previous discussion, dysfunctional habits are not created de novo but
are borne out of complex circumstances that may or may not be within direct control of
the patient. A central characteristic of the capacity for uptake is to attempt to “genuinely
understand the communicant’s point of View.”14 Uptake is therefore critical for the
ethical application of our pragmatic theory because it ensures the claims of patients are
not simply reduced into one—dimensional sound bites that match up with bullet points in
the a diagnostic manual or examination checklist.
Rather, uptake ensures that these claims are respected at a more intimate level——

and indeed this may require some personal risk-taking by the therapist who might
actually provide strategic self-disclosure to ensure their patient’s claims receive prOper
validation. With borderline patients, selective self-disclosure is inevitably fraught.
Nonetheless, selective self—disclosure performed by a skilled therapist should be
considered a dimension of uptake. It allows alliance building to take place and moreover,
helps the sufferer feel “real” thereby addressing an often-heard limitation in the capacity
of the patient to understand the consequences of their actions on others. As psychiatric
researchers Wilkinson and Gabbard explain, a limited kind of self-disclosure is
appropriate and should be narrowly defined in terms of “clinical honesty.” ‘5 The various
nuances of strategic self-disclosure and the transference-countertransference dynamic are
too complex to address here. Suffice it to say, clinical honesty possibly in which the

prudent use of self-disclosure enhances uptake is another skill that will ethically bound

Pragmatically motivated diagnoses.

151

Additionally, we should not confuse the concept of uptake with our folk
understanding of the concepts of respect or respectfulness. This is a critical distinction
Potter makes. First, she says, it is unclear that respectfulness should be considered a
virtue at all. Rather, it seems, respectfulness should be considered simply a necessary
disposition for being a minimally decent human being. Also, it might be the case that
particular species of respectfulness are themselves virtues (such as deferential respect or
self-respect), but the basic concept of respect doesn’t seem to entail anything more than

what we should expect from others or what we in fact owe others by default. In contrast,
uptake is the capacity to be not only respectful to another person but also remain fiilly
attentive to the needs and words of that person. In the clinical context, this capacity is
critical for cultivating the trust a patient must expect from their therapist in order to make
therapeutic progress.

A note on empathy: although above I mentioned them in the same breath, for
Potter empathy is distinct from uptake. Potter argues, in part, that empathy should be
characterized as a cognitive-emotional disposition, while uptake is an actual dialogical
capacity for a constructive conversation. Empathy, as a virtue, resides in the domain of
‘feeling-with others and morally attentive place-taking of others’ and it is marked by the
capacity to shift perspectives and connect on an emotional level. As Potter suggests, “If
clinicians are going to engage with their patients genuinely, they need not only to know

intellectually what sorts of attitudes are helpful, but also to learn to have appropriate

feelings for their BPD patients.”16 Potter provides a detailed description of how empathy
has been theoretically constructed and how those theoretical constructs might dovetail

with the therapeutic goals of treating borderline. For our purposes, we should take Special

152

note that empathy is a unique virtue that should be subsumed within our broader
pragmatic principle of beneficence. Although Potter breaks it out as a distinct virtue, it
seems reasonable to position empathy as a midlevel virtue that should motivate and
strengthen one’s capacity for uptake, which in turn will support trustworthiness.

Related to empathy is the concept of ‘world traveling’ described by feminist
philosopher Maria Lugones. This concept refers to one’s ability to shift away from one’s
own ‘world’—-which should be understood as the firll set of experiences that constitute
our understanding of ourselves—-to exist fully another world. The metaphor points to not
simply a change one’s understanding of another culture or perspective, but of a
fundamental epistemic transformation in one’s own identity, much the same as one might
experience after a visit to or living in a foreign land. This may occur unintentionally, as
Lugones suggests, because world travel is not simply a matter of acting differently in
various contexts. Rather, world travel is a radical shift in attitude, possibly even
contradictory to one’s former attitude. To world travel requires a level of “playfulness”
by which a perceiver crosses over to a new world or domain of discourse (game) and
plays by new rules or no rules at all.

An interesting dimension of world-travel is that it requires one to reject what Frye
has called “the arrogant perception” of normalcy. For Frye, arrogant perception is a form
of evil and fundamentally coercive trickery. The arrogant perceiver, through a
redefinition of terms like normal, healthy, or sane, takes control over those he perceives
to be flawed and reframes facts to support this coercive worldview. This often occurs
across the power divide between the clinician and patient, or between the nosologist and

the subjects of study (i.e. those who present the symptoms of interest for classification).

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So it is important that we emphasize here that arrogant perception is another pernicious
deficiency (in the vicious sense) that will undermine the implementation of our pragmatic
theory. What is necessary instead is what might be called “humble perception” as a
characteristic of empathic uptake. It is marked by a willingness of clinicians to accept the
possibility that, while they might have a robust and expert theoretical understanding of
psychiatry, psychology and medicine, they should approach each new individual case
with the curiosity of a novice.

Circling back to our central concept of uptake: in agreement with Potter and for
purposes of our implementing our pragmatic theory, I believe the virtuous capacity for
uptake should be considered to be fundamentally an “epistemic responsibility.”

Clinicians must be capable [mowers of their patients’ behaviors and juxtapose that
knowledge with their understandings of social power structures and conventional norms.
Linking uptake up with the virtue of insight—~which itself is an epistemic responsibility
to know oneself—~a clinician should be able to both absorb the patient’s perspective while
simultaneously remaining cognizant of influences and biases that might skew their
diagnosis or treatment plans. In the end, the capacity for uptake acts as an important
check on pragmatic ascriptions of mental disorder because it pushes clinicians to

maintain a nonjudgmental, albeit reasonably critical, perspective of their patients’
accounting of behaviors of concern. Uptake, when tempered by empathy, clinical

honesty and humble perception, should allow clinicians to engage in a pragmatically

motivated diagnosis thoughtfully and only after fully grasping their patient’s perspective.

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Macroethical Considerations

The above virtues can be broadened to apply to the important and ethically
fraught task of developing psychiatric nosologies. Again, as Agich has argued, decisions
about psychiatric categories (as with any categories of illness) are evaluative and as such
are instances of situational ethics. Thus, for psychiatric consensus panels and working
groups, a central goal will be to be crystal clear about the intentions and motivations of
their project. I have been arguing that, from a pragmatic perspective, the development or
elimination of categories of mental disorders should primarily serve the goal of
minimizing the suffering of individual patients, the broader community, and support
social progress in a very general sense (e. g. through a conceptual shift away from the
vice/mental illness dichotomy). The next series of philosophical-ethical considerations
will help keep our primary goal in full view as well as serve as a check on ulterior

motivations.

Critical Theory & Pragmatism

The ethical difficulties of diagnosing individual patients are magnified when we
consider the development of psychiatric classifications. To illustrate these worries, Reich
distinguishes between purposeful and unintentional misuse of psychiatric diagnosis. He
describes the well-known and infamous case of sluggishly progressing schizophrenia,
which was an invention of Soviet psychiatry (specifically the Moscow School), as an
example of purposeful creation and misuse of a diagnosis. As late as the mid-1980s,
Soviet medical publications described various new forms of schizophrenia, distinguishing
it from the mainstream form of schizophrenia found in Europe and the US. Both research

papers on Soviet brands of schizophrenia and the number of ‘patients’ had continued to

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increase dramatically through the 1970’s and 80’s. All this despite accounts by hundreds
of activists, and evidence from investigations by groups like Amnesty International, that
their incarcerations were a result of their anti-government political activities, and not a
medical condition at all.

This episode speaks not only to the possibility of intentional misuse of psychiatry
for political ends, but also to the complexity in the way such a dynamic may occur. At
the time there were psychiatrists in the USSR who genuinely believed that the category of
sluggish schizophrenia was properly constructed, scientifically valid, and that dissident
behaviors may have been a legitimate symptom of such a disorder. Moreover, in 1983,
the World Psychiatric Association published its list of subtypes of schizophrenia, which
included the subtypes used by Soviet psychiatry. The insidiousness of the Moscow
School’s brand of schizophrenia eventually led to a psychiatric regime within which
“psychiatrists who used this diagnostic system systematically tended to diagnose as ill——

and, often, genuinely to see as ill—persons who would not be diagnosed as ill anywhere

else.”17 Thus, our pragmatic theory must be armed with the epistemic apparatus to turn a
critical eye on the prevailing standards of mental illness and to step outside of the
scientific paradigm guiding psychiatric classification.

Such a perspectival shift is critical for addressing unintentional or gradually
occurring misuses of psychiatry. Such misuses may be shrouded by social trends and
obscured by larger social structures from which they emerge. For example, as Peter
Conrad has chronicled, the medicalization of hyperkinesis (the original name for what we
now call ADHD) was due in large part to the structure of educational institutions, where

attending to the individual needs of “hyperactive” students was increasingly challenging.

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The diagnostic slippage that occurred was thus difficult to recognize other than in
hindsight. This dynamic will be discussed in further detail below, as we discuss the ways
disease-construction can occur within the complex structure of economic, scientific, and
moral influences that constitute contemporary medicine’s place in Western culture.

For the pragmatic ascription of mental disorder to be ethically justifiable, working
groups need to have the knowledge and will to critically examine the history of
psychiatry, which is rife with examples of abuse and misuse. It is therefore incumbent on
the professionals involved in nosology to be ever vigilant of not repeating these abuses.
Thus, historical and sociological data must be integrated into the scientific evidence base
that is going to be used during the construction or alteration of mental disorders. Such
investigations compose what I mean by a pragmatic critical theory. Here I am not
necessarily referring to the exclusive deployment of the Critical Theory, i.e. the
philosophical and sociological work of Adomo, Marcuse, Habermas, et al. Indeed, the
critical theory to which I refer should be pragmatically oriented and both descriptive and
normative. It should be eclectic and draw methods in critical race theory, feminist
philosophy, economics, healthcare policy or any other field that might provide evidence
of how prevailing ideologies or power structures impinge on efforts to add or delete
mental disorders from the nosology. In fact, methods borrowed from fields such as
critical literary theory should play a part in this analysis. As we will see, the metaphorical
representations of borderline personality disorder in literature, movies, and poetry have
influenced the categorization and reinforced the prevailing beliefs surrounding borderline

women in particular.

157

Such beliefs will be the result of philosophical views about core concepts in
psychiatry. For example, most clinicians who are products of the Western liberal
philosophical tradition subscribe to a particular understanding about the nature of the self
as being an independent and largely atomistic entity freely existing in the world. As a
result, their concepts about the nature of volition and choice will reflect these theoretical
commitments. Similarly, one’s philosophical position related to questions of free will will
have obvious implications for the way in which they interpret the key concepts we
previously discussed related to determining problematic constellations of behavior or
habits. The point here is that the critical theory must be also turned inward—in much the
same way as the virtue of insight—to ensure nosologists are aware of their own
philosophical commitments. The goal is not to demand nosologists abandon their
commitments but rather remain aware of objections and controversies that surround such
commitments in order to arrive at a nonideological and ethically acceptable position.

In sum, the central goal of a critical theory is to provide classification reviewers
and developers the needed resources to achieve an ethically defensible nosology that
allows for an exposition of power structures, ideology and a plurality of philosophical
commitments. Those engaged in pragmatic revisions of mental disorder categories must
be on guard against less obvious and subconscious instances of ulterior motivation and
the way in which prevailing norms influence their positions about classification schema.
Such influences might come in the form of privileged social or political positions that
fixes the standpoint or limits the perspectives from which nosologists might view a set of
behaviors as a potential mental disorder. Addressing specific mechanisms by which this

happens is the point of our next consideration.

158

Appeals to NatureLTradition & Religious Mores

Reflected in the above comments is another underlying ethical component to the
pragmatic classification of mental disorder: nosologists must remain ever cognizant of
the way in which appeals to nature, tradition, and religion have been and can be used to
label individuals disordered. A well—known and outrageous example of an appeal to
nature in defining disease categories can be seen in the racist Antebellum disorder of
drapetomania, in which pseudoscientific claims about the natural role of blacks was used
to justify the construction of a disease to explain slaves who attempted to escape. Other
diseases such as dysaethesia aethiopica (or ‘rascality’) was attributed with causing
laziness in slaves, and remedied by at first gentle coddling but culminated in whippings
for ‘refractory’ cases. Of course, arguments from nature about racial or gender
differences have been used to justify any number of mental disorders from hysteria to
drapetomania.

The classic example of an appeal to traditional religious mores about sexuality
can be found in the labeling of homosexuality as a disorder in the early editions of the
DSM. While the arguments for inclusion of homosexuality in the DSM were framed in
terms of firnctional or biological appraisals, historical evidence suggests these arguments
were motivated more by an appeal to traditional values as extensions of religious dogma.
In his book, Homosexuality and American Psychiatry: The Politics of Diagnosis, Ronald
Bayer has charted the transformation of homosexuality from a “moral abomination” to a

mental disorder; a transformation that occurred throughout the development of psychiatry

from Freud to modern scientific psychiatry.18 Notwithstanding continued controversy,

159

Bayer and others have convincingly shown that the justifications used to include
homosexuality in the DSM were cleverly (or not so cleverly) shrouded assertions about
traditional values about ‘natural’ sexuality, all deployed under the guise of Freudian
theories about “pathologic parent-child relationships and early life situations.” These
justifications held up despite the fact that gay people did not feel “dis-ease” or
discomfort. Only after the work of Havelock Ellis, Magnus Hirschfield, and Alfred
Kinsey challenged the prevailing ideology about sexuality were gay activists able to
engage in a sustained and ultimately successful political movement to remove
homosexuality from the DSM. The demedicalization of homosexuality subsequently
resulted in a panoply of civil rights legislation protecting gay people from discrimination,
invasions of privacy and violence. As Bayer points out, religious groups mounted quick
and vigorous opposition to these legislative efforts because, not surprisingly, gay rights
were perceived as a threat to families and traditional mores more generally. Of course,
this battle continues to rage in the context of same sex marriage and gay rights more
broadly.

These thumbnails are provided simply to say that for the pragmatic theory to
succeed, it will be necessary to maintain a critical awareness of how seductive arguments
from nature can sometimes be. Likewise, the pragmatism I am endorsing must recognize
that claims based on traditional or religious beliefs permeate the politics of psychiatric
classification and should be kept at bay to ensure evidence not ideology drive work in
nosology. Granted, it would be unrealistic to argue that such influences can be expunged
from the domain of psychiatric classification. However, the pragmatism of my theory

accepts the reality of these influences and seeks to instill within individual practitioners

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and, through broader policies, nosological committees the capacity to grapple with these

influences.

Moral Entrepreneurship

Similar to the role played by religious groups who are ideologically driven,
sociologists such as Peter Conrad have highlighted the role of “moral entrepreneurs” in
the medicalization of social problems. Drawing on Howard Becker’s concept, Conrad
describes how moral entrepreneurs influenced the expansion of medical treatments for
hyperkinesis, which we now call attention deficit hyperactivity disorder (ADHD): “There
were agents outside the medical profession itself that were significant in ‘promoting’
hyperkinesis as a disorder within the medical framework. These agents might be

conceptualized in Becker’s terms as ‘moral entrepreneurs,’ those who crusade for

. ,,r9
creation and enforcement of rules.

Particular interest groups and movements of social activism, which may reside
within or outside the conventional domain of medicine, can also facilitate moral
entrepreneurship. As Conrad explains, “The classic example here is alcoholism, with both
Alcoholics Anonymous and the ‘alcoholism movement’ central to medicalization (with
physicians reluctant, resistant, or irresolute).”20 In fact, alcoholism provides a lucid
example of the explicit pragmatic logic that had been used for its categorization as a
‘disease’. In his well-known and controversial book, Heavy Drinking, Herbert F ingarette
chronicled this transformation of alcohol use from social problem to a disease. He noted

that within the scientific literature arguments were promulgated in favor of

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medicalization of alcohol dependence for the mere sake of social utility. He cited several
primary sources. Here are two examples:
(1) In specific circumstances it may be desirable for sociocultural, legal,
political, and therapeutic goals to label alcohol dependence as a “disease,”
perhaps especially at the time of acute physical symptomology. At the
same time the alcohol-dependent person may appropriately be labeled as
“sick”
(2) Calling alcoholism a disease rather than a behavior disorder, is a useful
device both to persuade the alcoholic to admit his alcoholism and to
provide a ticket for admission into the health care system?!
Fingarette argues that another driver of the ‘alcoholism-as-disease charade’ was the
passivity of a public who maintained a convenient trust in science to solve the problem of
heavy drinking. He states that it is simply easier to label alcoholism a disease rather than
explain or study the complex physiological, psychological, social and cultural causes of
the behaviors in question. “Our hunger for technical breakthroughs is readily fed by the
hand of those who promote the classic disease concept.” The mainstream media
propagates this cycle. First news sources misreport scientific results as verging on a
veritable breakthrough; the public quickly forgets such claims, only to be suckered into
believing a new claim that replaces the previous unfulfilled promise of breakthrough.
This dynamic plays out time and again and, as a result, Fingarette claims our misplaced
trust and hope in scientific solutions what are actually complex social problems is ’

reinforced. In this sense, media outlets serve as entrepreneurs who shill false promises in

the name of scientific progress.

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Of course, F ingarette’s skepticism could well be overstated. But we should take
note of the way in which he singles out social forces that influence the way diagnostic

categories coalesce around expectations created in nonscientific, popular, or less

scientifically informed sources.22 We should be skeptical of claims about singular
solutions or treatments—whether they are medications, therapy techniques, or recovery
programs—offered to remedy complex social problems. Such simplistic claims are
usually a red flag that entrepreneurship is afoot. We can see with personality disorders——
as they become more and more mainstream in the popular press and self-help literature—-
there is a risk of this dynamic occurring as well. For an ethically justifiable pragmatic
approach to addressing the problems caused by personality disorders, carefully
interpreted empirical evidence will prove essential for determination of both categories
and ongoing research priorities into treatments.

Another example of ostensible moral entrepreneurship is the action of the
National Alliance for Mental Illness to recognize boundary cases of mental illness as
equivalent somatic diseases. As I mentioned in the previous chapter, NAM] has
explicitly stated that mental illness represents a disease that is outside the control of the
sufferer and that mentally ill patients are not to blame. This claim is reasonable when we
consider core cases of mental illness but is much more controversial when we consider
how sufferers of boundary cases like narcissism or borderline may or may not have
control over their actions and choices. Should it be the case that suffers of personality
disorders are completely exculpated for the distress they cause to other people? NAMI’s
position seems to indicate such a no-fault disposition is the only justifiable way to

approach such cases.

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This conceptual approach to mental disorder represents moral entrepreneurship
precisely because it dichotomizes questions about personal responsibility and mental
illness by invoking the power of disease ascriptions as it also implicitly endorses a
particular worldview about the way suffers of personality disorder should be expected to
behave. It may in fact be the case that the no-fault policy is in fact the best way to
manage personality disorders, as I myself have suggested when discussing issues related
to personal responsibility. But NAMI’s reasoning is flawed, at least from a pragmatic
point of view because it relies on the false dichotomy that views psychiatric disorders as
mutually exclusive from other behaviors that are within mentally ill patients’ control.
Ironically, this position undercuts their other advocacy efforts to provide and ensure
mentally ill people with protections to make important personal and civic decisions from

informed consent to voting.

Disease Mongering & Conflicts of Interest

Related to moral entrepreneurship is the role of everyday financial
entrepreneurship in the expansion of medical categories. It is now well known that the
professional integrity of psychiatry has been seriously eroded by its financial
relationships with pharmaceutical companies. The general claim is that because so many
professional psychiatrists have financial ties to the makers of pharmaceuticals,
psychiatric categories have been generated or current diagnostic categories are expanded
simply to maximize the sale of drugs. In fact, an entire subfield of medical social science

has emerged—~complete with special editions of journals and an annual conference—that

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is focused on exposing instances of “disease mongering.”23 Empirical research suggests
these worries are well founded.

Pfizer’s redefinition of erectile dysfunction and the marketing of Viagra represent
a paradigm case of disease mongering. This was accomplished first by reconceptualizing
the parameters of erectile dysfunction through a very broad interpretation of the 1993
NIH consensus statement on ED, which stated that there millions of men suffered from
ED, though that was at best a wild guess because of a paucity of epidemiologic data.
Nonetheless, Pfizer claimed that “more than half of all men over 40 have difficulties
getting or maintaining an erection” This claim was undoubtedly based on a widely cited
paper in the New England Journal of Medicine which confounded epidemiologic data to
claim 20-30 million men in the US suffer from the disorder. We should note that the
author of this particular paper, Dr. Tom Lue, disclosed receiving grants and consultancy
pay from Pfizer and a half dozen other pharmaceutical companies.

There are too many examples like Viagra to discuss here. But in psychiatry, the
problem is especially grave. From ADHD to bipolar disease, the role of pharmaceutical
corporate interests have had a profound influence on everything from school board
policies and pedagogical best practices to prescribing patterns of antipsychotics for
children as young as 3 years old. As Phillips has shown, the role of the pharmaceutical
company in schools has expanded through the “in kind” support and the provision of
curricular materials in much the same way doctors receive “educational literature.” In
1997 Novartis, the maker of Ritalin, in collaboration with the National Association of

School Nurses, provided 11,000 school nurses 3 “resource” kit that included resources on

ADHD and how to treat it with direct links to Novartis drugs.24 This should not be a

165

surprise, as it is now generally accepted that Ciba—Gegy (now Novartis) founded the
advocacy group Children and Adults with Attention-Deficit/Hyperactivity Disorder

(CHADD). CHADD continues to receive about a third of its annual income directly from

pharmaceutical companies.25 And now there are direct-to-consumer TV ads about adult

ADHD that points viewers to a site to get free info (http://www.adhdactionguide.com).

The site is created by the pharmaceutical company Shire, makers of Adderall.26

A 2008 study by Colgrove, et al. called attention to DSM work group members
who have financial ties to pharmaceutical companies. They noted that 56% of DSM
panel members have financial ties, and in some specialties like mood disorders 100% of
panel members had financial ties. The findings of this study were widely publicized

prompting a number of articles in the popular press. Indeed the concern about conflicts

of interest has become so great that Congressional leaders have started to investigate.27
While it is true that the correlation of members’ financial interests and their work on
psychiatric classification does not necessarily entail that those interests caused the
creation of medical categories, it is nonetheless critically important that the pragmatic
theory must ensure public trust by forestalling both the appearances of and actual
conflicts of interest between psychiatry and the pharmaceutical industry. Public trust is
essential if medical categories are to be taken seriously.

Trust can be achieved in part through greater transparency of financial ties, as
well as setting limits on amount of money individual psychiatrists are allowed to earn
through by way of contracts with drug makers if they are to be part of a DSM task force.
Indeed, the current DSM-V task force has attempted to take seriously the need for

transparency and compensation limits and has set out a strict set of guidelines for task

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force members. Unfortunately, the numbers culled from the Cosgrove study reflect the
failure of these guidelines to inspire hope in the objectivity and trust in the authentically
beneficent motivation of psychiatric nosologists. Policy suggestions for how to address
this very significant problem will be described in chapter 8.

Psychiatric globalization—or the tendency for American or western concepts of
mental disorder to spread across the globe displacing indigenous concepts of normalcy
and mental disorder—-—represents another ethical concern closely related to moral
entrepreneurship and disease mongering. In a recent New York Times article, Ethan
Watters describes the dynamic wherein American ideas about mental illness—and those
illnesses themselves—actually spread across the globe, in much the same way as a virus:

Western drug companies dole out large sums for research and spend

billions marketing medications for mental illnesses. In addition, Western-

trained traumatologists often rush in where war or natural disasters strike

to deliver “psychological first aid,” bringing with them their assumptions

about how the mind becomes broken by horrible events and how it is best

healed.
As a result, Watters contends, American psychiatric categories are crowding out other
cultures’ understandings of the meanings, causes, and significance of mental disorders.
What this process illustrates is the profound and widespread impact American ascriptions
of mental disorder can have. The pragmatic nosologist must keep these concerns in mind
by recognizing that the creation, alteration, or elimination of a diagnostic category is an

ethical decision with far-reaching ramifications.

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Conclusion

The goal of this chapter was to sketch the ethical components of the
comprehensive theory. The first set of ethical considerations applies particularly to
individual clinicians and can be thought of as core virtues that enable the diagnosis and
treatment of mental disorder deemed as such for pragmatic purposes. The second set of

ethical considerations applies more broadly to the nosological enterprise considered as a
whole. It is true that such macroscopic perspective might be overly simplistic———after all,
broad movements of medicalization are incredibly complex and caused by countervailing
and often contradictory social forces. Nonetheless, the macroethical considerations
proposed here should be thought of as conceptual proposals or touchstones used to guide
the classificatory efforts of DSM task forces. In general, then, the subtheories and
considerations presented in this chapter are proposed as critical elements that should
guide the application of the pragmatic theory when considering whether a constellation of
behaviors is a mental disorder or not. They serve as checks on the process of
medicalization as well as ethical touchstones in the reexamination of current psychiatric
categories. These ethical considerations, among others, will be more fully illustrated in
the next chapter, as we apply our comprehensive pragmatic theory to the case of

borderline personality disorder.

1. A note on my terminology: I use the terms ‘ethical subtheory’ and ‘ethical consideration’
interchangeably to refer to specific sets of arguments, paradigm cases, or methods of analysis that I believe
are needed to circumscribe the pragmatic theory within ethical bounds. ,

2. Thomas Szasz, “Psychiatry and the Control of Dangerousness: On the Apotropaic Function of
the Term ‘Mental lllness,”’ Journal of Medical Ethics 29 (Aug. 2003): 227-230.
3. Excerpt from DebatesDebates, a nationally-broadcast public television show produced and
directed by Warren Steibel at HBO studios in New York City. This show, entitled "Should The Insanity
Defense Be Abolished?,“ was taped on August 26, 1996. Show #110 transcript accessed on April I, 2010

via www .szasz.coml insanity .pdf

168

 

4. Peter Conrad, “The Discovery of Hyperkinesis: Notes on the Medicalization of Deviant
Behavior,” Social Problems, 23, no. 1 (I975): 18.
5. Nancy N yquist Potter, Mapping the Edges and the In-between: A Critical Analysis of
Borderline Personality Disorder (New York: Ox ford University Press, 2009).
6. lbid., 7.

7. Ibid, 124.

8. John Dewey, “Moral Judgment and Knowledge,” in The Essential Dewey Volume 2: Ethics,

Logic, Psychology ed. Larry A. Hickman and Thomas M. Alexander, (Bloomington, IN: Indiana University
Press, 1998), 338.

9. Porter, 2009, 129.
10. lbid., 128.

11. Walter Reich, “Psychiatric Diagnosis as an Ethical Problem” in Psychiatric Ethics 3rd ed., ed.
Sidney Bloch, Paul Chodoff, and Stephan A. Green (New York: Oxford University Press, 1999), I93.

12. Ibid, 205.

13. Marilyn Frye, The Politics of Reality: Essays in Feminist Theory. Freedom, CA: Crossing
Press, 1983), pg. 88.

I4. Potter, 2009, I41.

15. Sallye M. Wilkinson and Glen 0. Gabbard, “Therapeutic Self-Disclosure with Borderline

Patients,” Journal of Psychotherapy Practice and Research 2, no.4 (1993): 282-295.
16. Ibid, 171-172.

17. Reich, I999, 197.

18. Ronald Bayer, Homosexuality and American Psychiatry: The Politics of Diagnosis (Princeton,
NJ: Princeton University Press, 1997).

19. Howard S. Becker, Outsiders: Studies in the Sociology of Deviance (New York: The Free
Press, 1973); Conrad, 1975, 12-21 (see n.4).

20. Peter Conrad, “The Shifting Engines of Medicalization,” Journal of Health and Social
Behavior 46, no. I (2005): 3-14.

21. Herbert Fingarette, Heavy Drinking: The Myth of A lcoholism as a Disease (Berkeley, CA:
University of California Press, 1988), 26.

22. Importantly, for F ingarette, these forces don’t cany the weight of his argument, which actually
refutes the empirical claims and assumptions that alcoholism is a disease.

23. The Inaugural Conference on Disease—Mongering was held in 2006 in Newcastle Australia.
See also: The PLoS Medicine Disease Mongering Collection available online:
http://www.ploscollections.org/home.action (accessed February 19, 2010)

24. Christine B. Phillips, “Medicine Goes to School: Teachers as Sickness Brokers for ADHD,”
PLoS Med 3, no.4 (2006): 6182. doi:10.l37l/journal.pmed.0030182

25. CHADD’s 2009 annual statement reported 35.9% of total revenue was from the support of
pharmaceutical companies Eli Lilly, McNeil, Novartis, and Shire US.
http://www.chadd.org/Content/CHADD/AboutCHADD/Reports/default.htrn (accessed May 1, 2010)

26. Tom Tomlinson, pers. comm.

27. Mark Moran, “Senator wants APA records of drug-industry interactions.” Psychiatric News
43, no. 16 (2008):l-3.

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CHAPTER 6
AN ETHICAL-PRAGMATIC RECONSTRUCTION OF
BORDERLINE PERSONALITY DISORDER (PART I)
Introduction
In the previous two chapters, I described what I take to be a pragmatic theoretical
extension of a naturalistic nosological theory. I offered this pragmatic theory to help
categorize personality disorders, which were described in terms of problematic and
pervasive constellations of socially dysfunctional behaviors (habits), and which cause a
form of suffering that intersects with the ameliorative goals of psychiatry and clinical
psychology. As I emphasized in previous chapters, this pragmatic theory, although built
off of a naturalistic model, does not necessarily depend on clear biological correlates to
justify the ascription Of mental disorder to a problematic constellation of behaviors.
Rather, the justification comes from an acknowledgment that the behaviors are both
socially dysfunctional and cause suffering either to the patient or to others or both. When
considering the harm caused to others, I proposed using a public health model to link
personality disorders to the other forms of mental illnesses oftentimes experienced by
those who have close relationships with persons with personality disorders.
In Chapter 5, I explicated several important ethical subtheories and considerations
that undergird an ethical pragmatic theory of mental disorder. I argued that subtheories
would operate across two very broadly defined domains: that of the individual mental
health clinician and that of the profession of psychiatry and psychology where
nosological categories and treatment standards are established, validated, and refined.

Recall the key ethical demands placed on individuals turned on a set of virtues allied with

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'llc'

beneficence. These included trustworthiness, insight, and the capacity for empathy and
uptake. Likewise, at the macroscopic level, I argued the pragmatic theory must be
bounded by several ethical checks, which aim to both recognize and prevent abuse and
misuse of ascriptions of mental disorder. These checks primarily turned on a critical
analysis of the power and influence of social power structures, moral entrepreneurs,
traditional and religious mores, and financially motivated disease mongers.

In the next two chapters, I will more fully illustrate and apply the pragmatic
theory and its ethical subtheories by analyzing the case of borderline personality disorder,
which is one often personality disorders listed in the DSM-IV. My first step will be to
offer a critical feminist analysis that exposes oppressive forces and structures that have
been foundational to the standard construction of borderline. To do this, I will provide an
historical sketch of the development of the standard model of the disorder. The purpose
of presenting this history is to advance the ethical-pragmatic theory by showing first how
the standard construction of borderline may have been built not primarily on the ethically
justifiable motive of relieving mental anguish, but rather on questionable judgments
regarding the proper role of women in society. Moreover, I will argue these judgments

were themselves built upon a more fundamental set of philosophical assumptions about
the ideal nature of the self, which has been roundly criticized by feminist philosophers as
being implicitly gendered. To accomplish this, in addition to feminist critiques of
liberalism and historical work on the origins of “hysteria” and “madness,” I will
synthesize insights from Janet Wirth-Cauchon’s comprehensive study, Women and

Borderline Personality Disorder and, again, I will, draw upon Nancy Potter’s recent

philosophical examination of borderline.1

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In providing this history, I will Show that the standard construction of borderline
serves as an anti-paradigm—to adapt a term from casuistry——to then be able to offer a
way to understand the constraints within which our pragmatic theory should be applied.
In other words, the standard construction of borderline provides us with an example of
what an ethically impoverished pragmatic theory of mental disorder might produce: a
category of mental disorder that is fraught with questionable assumptions, which in turn
leads to both diagnostic schemas that reflect these assumptions and therapies that have
remained largely unsuccessful. To be clear, the following historical sketch of borderline
is not meant as a definitive critique of borderline disorder nor is it an attempt to argue
that what is today recognized as borderline personality disorder is illegitimate. My goal is
simply to use the critical literature on the history of borderline to point out how we may
move forward with a more ethically justifiable pragmatic reinterpretation of the
disorder’s categorization, diagnosis, and treatment.

To support this line of analysis, I will describe how the standard construction has
been reinforced and reflected in the ways its symptoms have been caricatured both in the
professional literature and in popular venues. With such evidence in hand, it is
reasonable to assert that the standard construction has been pragmatically motivated,
especially in the way it enhanced and reinforced a traditional power structure, shifting
blame and responsibility to the individual patient, as it helped to explain away social
troubles and difficult behavior as instantiations of individual madness. Thus, the
pragmatic ascription of disorder was made for the ethically deficient reasons. Again, I
contend that, because of these nefarious influences and motivations, the standard

construction of borderline represents an anti-paradigm of an ethically justifiable

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pragmatic ascription of mental disorder. As I will Show, the ethical shortcomings that are
embedded within the standard construction make borderline more difficult to both
appropriately diagnose and efficaciously treat.

A key juncture of my analysis will be to recognize the deficiencies of the standard
construction and then to provide an ethically justifiable pragmatic reconstruction of
borderline using the model I have developed. In order to respond to the problems I
identify with the standard construction, in the next chapter I will apply the pragmatic
theory within the constraints of the particular ethical subtheories described in chapter 5.
This contextual reanalysis will reveal that the symptomatic behaviors of the borderline
patient are actually somewhat understandable—they reflect the deep frustration, anger,
helplessness and fear one might expect in anyone who has suffered trauma, abandonment
or serious abuse. Thus, a key pragmatic distinction will be to recognize the symptoms of
borderline as legitimate responses to and the sequelae of psychological and physical
abuse and injury, but also as self-defeating in the way these behaviors are deployed by
the patient. One goal, also described in the next chapter, will be to refine the clinical
understanding of borderline’s symptomatic dysfunctional behaviors so that clinicians can
help patients to transform and refocus diffuse anger toward more constructive ends. Let
us now critically review features of the standard construction of borderline personality
disorder that cause its current categorization, diagnosis, and treatment to be both ethically

defective and pragmatically suboptimal.

Basics

As I began to describe in Chapter 4, borderline personality disorder is marked by

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the essential feature of “a pervasive pattern of instability of interpersonal relationships,

self-image, and affects, and marked impulsivity that begins by early adulthood and is

”2 The DSM estimates prevalence of borderline

present in a variety of contexts.
personality disorder in the general population to be about 2%. Coid, et al. in their meta-
analysis, have indicated that estimates on the prevalence of borderline range from 0% -
3.2%, depending on the version of the DSM used and diagnostic techniques.
Approximately 75% of all diagnosed cases of borderline occur in females.

Persons diagnosed with borderline experience intense fear of real or perceived
instances of abandonment—so much so that their behavior, affect, and cognitive habits
are dramatically reactive to this fear. In their frantic efforts to avoid abandonment,
borderlines might, for example, threaten suicide (8%—10% complete suicide) or self-
mutilate (cutting or burning). Impulsivity dysregulation may occur as behaviors such as
gambling, binge eating, substance abuse, unsafe sex, and reckless driving. Borderlines
exhibit a general dysphoria, which is randomly interrupted by angry outbursts, anxiety, or
panic. These outbursts, as illustrated in the vignettes in Chapter 4, often occur when the
borderline person feels threatened by the real or perceived possibility of abandonment.

These core features and several associated features contribute to the borderline
person’s inability to cultivate and maintain long-term friendships and relationships. In
particular, as one psychiatrist explained to me, borderlines tend to “glom” on to peOple
because of their fear of being alone or abandonment. This often-aggressive behavior
causes others to push borderlines away, resulting in the abandonment borderlines So
frantically had tried to avoid. Typically, the borderline person will then decide their

abandoner was evil in some way and this reinforces their black and white view of

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others—those who are unquestionably with them are idealized, anyone perceived as a

threat is considered evil. This interpersonal volatility causes borderline persons to
experience instability in their professional lives as they find themselves constantly
unsettled in their jobs and career plans. Persons with borderline experience significant
identity disruptions and instability, which is both part of the etiology and exacerbates the
symptoms of the disorder. The standard construction has defined borderline in terms of
other mental illnesses as well. As Gunderson describes, in addition to including
borderline on the personality disorder spectrum, researchers have suggested considering

borderline as a part of schizophrenia spectrum, affective disorder spectrum, or, more

recently, the bipolar spectrum.3

An Historical Sketch
I now wish to show that this construction of borderline disorder belies a degree of
gender bias, which transformed and retransformed the disorder until it was officially
recognized in 1980 in the DSM-III. To do this, let us briefly review the historical
construction of borderline disorder, so that we may more fully grasp the social and value
laden characteristics of the contemporary disorder. I will not review in detail the
genealogical studies of the medicalization of madness viS-a-vis power structures and
women’s health. My central goal here is to provide enough historical background from
which to then claim a bias has infiltrated the ways by which the features of borderline are
characterized. This bias turns on the classically liberal philosophical concept of the self,
which favors the outwardly stable, rational, unwavering male self over the unstable,

emotional, and “uppity” woman and that to reconstruct borderline in an ethical way, this

175

needs to be recognized. Thankfully, Wirth-Cauchon, in thorough F oucauldian fashion,
provides a genealogy of the three discrete “phases of meaning” that borderline has
traversed, which provide us with thumbnails for this historical sketch.
In the earliest phase, the British doctor Andrew Wynter described patients
existing in an allegorical borderland “who appeared neither mad nor sane, and yet who

were described as socially marginal and transgressing the boundaries of Victorian social

class.” 4 I should note here, Wynter’s description is probably based upon, at least in part,

Prichard’s concept of moral insanity, which was explicated decades earlier in his Treatise

on Insanity.5 The name ‘borderline’ itself depended on the traditional dichotomy
between psychosis and neurosis, thus we can track that back to the 18605 and 708. In the
next section, we will turn our attention in some detail to the term ‘borderline,’ where we
will see that the metaphorical description is an important basis for the development of the
mythology of the borderline woman in conflict with the liberal self. For now, it is
important to note that the origins of the modern disorder were characterized by an
understanding of borderline as an enigmatic illness, residing somewhere between hysteria
and sanity, which defied treatment and clear categorization.

During the second phase, the term “borderline” received its first formal mention
in 1938 by Adolph Stern, who used it to classify patients that appeared to reside within
the nexus of neurosis and psychosis.6 During this phase, borderline was integrated into
the Freudian psychoanalytic tradition as a disruption in basic object relations and
recognition. In his later writings, Stern laments that patients on the borderline are

severely and desperately ill. They happen to be an exceptionally challenging group of

patients because of their tendency for transference, which occurs when a psychiatric

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patient projects her feelings or emotions onto the therapist. Transference might manifest
as blame of the therapist, the view that the therapist can fill the void left by an absent
parent, or as sexual interest in the therapist. More importantly, the borderline patient was
described as being adept at eliciting counter-transference wherein the therapist actually
falls into his unrealistic transferred role and reacts to the patient from within that role.
The apparent transference/counter—transference dynamic that occurred during analysis
sessions made treatment of borderline so difficult as to be deemed “incurable.” Indeed,
the borderline label seemed to be synonymous not-so-much with a particular neurosis or
psychosis, but rather with characterizing a type of incorrigible patient who was typically

a woman. As Gunderson points out, during this phase, borderline was a product of the

psychoanalytic paradigm, in which neuroses were ‘analyzable’ and psychoses were not.7
AS their name indicates, borderlines resided somewhere along that edge.

Also during this second phase, Kemberg provided the most well developed
psychoanalytic account of borderline conditions, grounded on the Stern’s notion that the
borderline patient suffers from a disorder that is neither a neurosis nor a psychosis and, as
we will see, he applied Object relations theory to explain the fragmentation of the
borderline individual. He subsumed his construction of borderline within the larger
framework of ‘hysterical’ personality types, defined by emotional lability, over-
involvement, the combination of dependent and exhibitionistic traits, pseudo-

hypersexuality and sexual inhibition, selective competitiveness with men and women,
(I . . . 8
an masochistic traits.

In describing the specifics of these symptoms, two points stand out and will be

revisited when I discuss the gendered dimensions of the standard construction. First,

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Kernberg states that over-involvement “may appear quite appropriate on the surface.

Nonsophisticated observers usually consider it in women as typical feminine charm.”9
Likewise, Kernberg says that “[h]ysterical women who tend to compete with men (in
order to deny their sexual inferiority) tend to develop stable characterological patterns in

this regard; in their competitiveness with other women, oedipal rivalry tends to

predominate over other origins of the competitiveness.”10 Second, Kemberg’s description
of the transference—countertransference dynamic is also telling. He says,

In dealing with borderline personality organization, dedicated therapists of

all levels of experience may live through phases of almost masochistic

submission to some of the patient’s aggression, disproportionate doubts in

their own capacity, and exaggerated fears of criticisms by third parties.

During these phases, the analyst comes to identify himself with the

patient’s aggression, paranoid projection, and guilt.H
The upshot is that the borderline patient is so difficult that the frustration of the therapist
and their defeat is a result of the disorder and is the patient’s fault.

The third phase of meaning began in 1980, when borderline was officially
recognized within the DSM-III as a personality disorder. The publication of the DSM-III
marked a significant paradigm shift in the way in which mental illnesses, and particularly
personality disorders, were described and categorized. But this Shift did not come out of
nowhere. As Klerman describes, the DSM-III represented a neo-Kraepelinian
classification schema—a nosological structure inspired and informed by the work of turn-

of-the-20th century psychiatrist (and discoverer of bipolar disorder, schizophrenia, and

co-discoverer of Alzheimer’s disease) Emil Kraepelin.12 Kraepelin’s nosology—itself

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divided into the two categories of manic-depressive insanity and dementia praeocox-——
was the first attempt to build a scientifically grounded psychiatric nosology that followed
the medical model by reducing mental illness to disorders of the brain, which were
empirically observable, somewhat predictable in that they were shown to be heritable,
and distinguishable from behavioral idiosyncrasies. The DSM—III reflected these
scientific ideals in a number of ways, most obviously in the fact that it was constructed
only after reliability testing and validating field trials were conducted. This was the first
time medical practitioners had attempted to validate their nomenclature prior to its
becoming official. This effort continued as the validation methods proposed a decade
earlier by Robins and Guze—analyses that included clinical description, laboratory'study,
follow-up study, and genetic studies—were used to test the validity of the newly defined
borderline disorder.l3

Also, among the many important changes in the DSM-III was the redaction of
psychoanalytic terms and concepts, such as the word ‘neurosis,’ and the elimination of
homosexuality as a disease (in the DSM-III—R). But the most significant conceptual Shift
was the move away from the biomedical notion of a ‘disease entity’ that caused mental
illness toward a multiaxial categorization of mental illness. In earlier versions of the
DSM, personality types (i.e. hysterical personality, passive-dependent personality) were
constitutive of other mental illnesses, but were not, themselves, considered disorders. In
the DSM—III, personality disorders took their place within Axis II, neatly broken out from

other conditions as discrete pathologies “existing concurrently with other forms of

psychopathology.”14 The new multidimensional description entailed that personality

assessments be central to diagnosis and treatment. By creating a clinical dimension

I79

solely for personality evaluation, Wirth-Cauchon argues, the DSM-III working group
opened up “new terrain” for medicalization of the whole person. Indeed, we see this
rather clearly in the original definition of Axis II disorders: “A clinically significant
behavioral or psychological syndrome or pattern that occurs in an individual and that is
typically associated with either a painful symptom (distress) or impairment in one or
more important areas of functioning (disability).”ls Each of the disorders was clustered
into categories that stipulated dysfunctions be assessed in the context of social
expectations.

In his 1984 meta-analysis, John Gunderson describes the features of borderline
across six domains—affect, identity, interpersonal relationships, impulsivity, psychosis,
and miscellaneous-~against which he superimposed more specific findings in the
literature. Key features within the domain of affect included anger, depression, and
chronic feelings of emptiness. Identity disturbance (or an unstable sense of self) was the
central feature of the identity domain. Across the interpersonal relationship domain,
Gunderson found that anaclitic or highly emotional, stormy, and angry interpersonal
interactions were common. According to this analysis, borderlines also share features of
impulsive drug and alcohol use, self-harm, manipulative suicide gestures, and ‘unstable
sex’ (promiscuity). Although now slightly dated, this picture of borderline was culled

from dozens of papers and represents the standard construction of borderline that is today

still widely reiterated.16 Later, Zanarini and Frankenburg offered a similar picture
defining the inner pain of the borderline as both cognitive and affective, with its etiology

rooted in traumatic early life events or abuse, which, in combination with a vulnerable or

hyperbolic temperament, produced the disorder.‘7

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A few years after the publication of the DSM-III, in what seems to be the first
published feminist critique of the manual, Marcie Kaplan argued that the fundamental
shift toward multiaxial diagnosis had been a catalyst for the institutionalization of sexist
bias within psychiatric nosology. In response to the way in which personality disorders
were framed, Kaplan asks,

What does impairment in social or occupational functioning mean? I

believe these criteria contain assumptions and then generate diagnoses

accordingly. For instance, is a woman unemployed outside the home
impaired in occupational functioning? Is a man who is employed outside

the home and thus never there when his children come home from school

impaired in social functioning? Evidently users of DSM-III assume not, or

many “healthy” individuals who assume traditional gender roles would

have diagnoses; yet a woman who neglects her children and a man who

can’t hold down a job—perhaps healthy individuals who assume

nontraditional roles——may be labeled impaired by a diagnostician.‘ 8
We will consider some of Kaplan’s concerns more directly below. For now, it is
important to recognize that the normative assumptions built into the standard construction
of borderline over the course of the past several decades had become further entrenched,
more widely expanded, and officially codified with the DSM-III.

Today’s DSM-IV—TR and the soon-to-be completed DSM-V mark the continued
development and modification of the multiaxial system, with refinements made in
response to the criticisms leveled against the DSM-III. I should note that in the proposed

DSM-V, the procedure for diagnosing of personality disorders could change. Instead of

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ten disorders, there will be five general personality disorder types. Dozens of personality
traits (within a few trait domains) are rated according to relevance. This assessment is
intended to provide therapists a general picture of their patient’s personality type, even if
they do not have a personality disorder. The specific boundaries for diagnosing a
personality disorder within this structure have yet to be determined.

Nonetheless, the current diagnostic criteria of borderline disorder remain
controversial for both philosophical and medical reasons; it is a controversy that I believe
is the result of ideological biases that helped to produce these criteria. Examining the
ways in which borderline women have been portrayed can help us to continue to uncover
biases that are built into the standard construction of borderline. After a brief look at
representations of borderline, we will shift back to the philosophical examination of how
the borderline woman serves as a foil for a more fundamental philosophical standard of
the rational autonomous self, which has served as the template for what constitutes the

ideal of a normal personality.

Tropes & Caricatures of the Borderline Woman

Metaphor is a powerful tool often used to express the inexpressible and convey a
deeper message about an individual, group, situation, or a process. As Rooney has
argued, metaphors are more than “stylistic embellishments”; rather, “the metaphor

reveals much more about historical background assumptions and imaginative

underpinnings.”19

Metaphorically speaking, metaphors are the smugglers of normative
claims. It is therefore reasonable to assert that the metaphors associated with the

borderline woman reflect certain assumptions about madness, insanity, and women’ s

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emotional instability, which also reveal gender bias that is ultimately instantiated more
formally in the psychiatric nosology. Although the creative choices made to explain
borderline by professionals, patients, and lay observers should not be taken as the final
word on how borderline has been socially constructed, I think it is safe to assume that
these choices do reveal latent assumptions and biases embedded within that construction.
This is simply to say an analysis of metaphorical portrayals can serve as a starting point
for uncovering implicit ideologies or motivations. This is the kind of critical analysis that
is required by our pragmatic theory; this begins with the name of the disorder itself.
Recall during its early phases of meaning, we found evidence of bias in the

1abel-itself a metaphor—of the ‘border land.’ As Wirth-Cauchon explains, the term
borderline was a both a symbol and reflection of the lack of understanding of a certain
group of patients. Citing Martin Leichtrnan, Wirth-Cauchon says that “the image of the
borderline disorder” was conveyed as “a vast uncharted ‘territory’ of madness that

scientific rationality discovered, explored, and demystified by bringing to it to light of

scientific reason.”20 In Leichtman’s words, “those who dealt with the borderline concept

in this period resemble explorers, trappers, and pioneers who ventured out from more

settled areas to map and cultivate an undefined wilderness.”21 They were depicted. as
men who were sent out to conquer and tame nature.

The picture of the borderline woman who dwells in a strange and fantastic terra
incognito is fully painted in Christine Ann Lawson’s book, Understanding the Borderline
Mother. Lawson makes explicit connections between the relationships children have
with their borderline mothers and Lewis Carroll’s Alice ’s Adventures in Wonderland

where, as we know, logic and reason are abandoned atop the rabbit hole. In Lawson’s

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words: “Like Alice in Alice 's Adventures in Wonderland, children in Borderland are

puzzled by the contradictions of their world and live on the fine line between sanity and

insanity.” 22 Continuing the allegory: “Children of borderlines have been down the rabbit
hole. They have heard the Queen of Hearts order everyone beheaded. They have

attended the mad tea party and argued with the Duchess for the right to think their own

thoughts. They grow weary of feeling big one minute and small the next.”23

Lawson characterizes borderline mothers as ‘make-believe’ women, whose
intense fickleness and power could be intriguing if it were not so venomous. In the body
of Lawson’s book she goes on to cast four types of borderline mothers: the waif mother,
the hermit mother, the queen mother and the witch mother. The waif mother plays the
role of the helpless victim of past abuses and finds life too hard to live. She responds to
oppressive environments through helplessness and resignation. The hermit mother is
secluded and paranoid; she lives in fear and distrust. She is obsessive compulsive. The
queen mother is self—centered, flamboyant, ambitious and intimidating. She is
preoccupied with her image and that of her children. Finally, the witch mother—the most
terrifying of the four—shifts in and out of the other roles, but, ultimately, She is described
more-or-less as the embodiment of evil, as she summons her internal rage and anger to
abuse her children and annihilate anyone she perceives to be a threat to her delicate
persona. Outside of the home, Lawson describes how she divides groups, forms fleeting
alliances, and ultimately feels a sense of sadistic enjoyment when those with power or
authority are diminished.24 Drawing on mythology, Lawson claims, “The Medean
Mother is the most pathological (and rarest) type of witch.” She lives according to the

. . ,2
mantra, “LIfe 15 war.’ 5

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We also see various metaphors and caricatures of the borderline woman brought
to life on television and in film. Lawson claims Joan Crawford, described by her adopted
daughter Christina as emotionally and physically abusive and portrayed in the movie
Mommie Dearest, is a paragon of the borderline mother. Glenn Close’s character in Fatal
Attraction provides a caricature of the hypersexual, violent, and jilted borderline woman
whose psychotic rage is triggered after a dalliance with a married man. To my lights, the
starkest example of the Medean Mother was portrayed by the character Livia Soprano,
Tony’s mother, who feigned senility in her attempt to murder her own son. Another
borderline woman appears in later episodes of The Sopranos in the character of Gloria
Trillo with whom Tony has a torrid affair. Although Trillo starts off as an independent,
successful, and charming woman, she comes to represent an evil obsessive temptress and
reincarnation of Livia. She eventually hangs herself after Tony rejects her.

In Henry Selick’s animated screenplay Coraline, we find an exceptionally creepy
version of the witch-borderline mother. Young Coraline discovers her ‘Other Mother’
who lives in an alternate universe, Other World, accessible to Coraline through a closeted
portal that actually resembles a birth canal. Initially, Coraline is seduced by her Other
Mother’s warmth, charm and attention; Other Mother spoils Coraline with her favorite
food and showers her with affection. Coraline eventually comes to realize the true evil of
this ersatz parent when she discovers the ghosts of previously enslaved children, whose
eyes and souls the viciously cruel Other Mother had removed. Fortunately, Coraline
figures out a way to eventually outfox and escape Other Mother who, in their final battle

scene, metamorphoses into her true form—a giant arachnid.

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All of these female characters radiate their rage, spread chaos, and possess
disingenuous and deeply disturbed personalities. Though they are only metaphors and
caricatures, the potency of such characters defines a narrow aperture, or what Rooney

describes as the “focus and frame,” through which the metaphorical borderline woman is

understood as “the subject of discourse” in both medicine and society.26 Of course there
are many cultural renderings of psychotic or psychopathic men. However, to my
knowledge, there are no portrayals of borderline men specifically, at least none that have
reached the level of popularity of the above examples. In fact, several of these well—
known representations of borderline women have been used as case studies to teach
young clinicians about the disorder, thereby amplifying the power of the standard
construction and its corresponding tropes.” I therefore contend that both the historical
mythology of the sick outcast of the borderland and the metaphorical descriptions of the
borderline woman are actually conceptually interdependent and self-sustaining.

To continue our critical analysis we should dig a bit deeper and ask, “From where
do the metaphorical renderings and historical archetypes of the borderline woman derive
such explanatory power?” Let us now look at the way in which these constructions and
depictions result from an even more basic philosophical assumption related to the ideal
nature of the self—an ideal that, in turn, drives psychiatric classification and intervention.
As I will argue, revealing and realigning these unspoken phiIOSOphical commitments is a
necessary step toward reconstructing borderline within the ethical constraints of our

Pragmatic theory.

The Liberal Self

The goal of this section is to draw upon feminist philosophical insights to

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critically examine how the liberal self as a gendered concept serves as the foundation for
assessing personalities as disordered or healthy. The concept of the autonomous
transcendental self, as systematized most clearly by Kant, is that of an individual moving
through the world autonomously. He makes rational decisions according a set of absolute
moral rules, which are a priori and are accessed through the apparatus of pure reason.
Though some feminists, particularly Marxist and radical feminists, challenge liberalism’s
emphasis on individualism, other liberal feminists continue to accept, adapt, and refine
the concept of autonomy to accommodate feminist concerns. Although the concept of
autonomy has been augmented to answer objections that it ignores the relational
dimensions of lived experience, the individualistic core of the liberal self remains solidly
intact. For example, before proposing their own version of autonomy, Anderson and

Honneth (2005) acknowledge the “individualistic conception of autonomy not only has

historical pedigree; it also has come to seem just obvious to many.”28 Indeed, we often
assume that for a child to develop into a fully autonomous adult means they Should
become independent, self-sufficient, and capable of meeting life’s challenges on their
own. Signs of continued dependence on others are taken as evidence of developmental
delay and social dysfunction.

Similarly, the rational core of the autonomous person is a sine qua non of the
ideal self. The capacity to make rational decisions equips an autonomous person with the
necessary aptitude to correctly navigate life’s complex social, ethical, and political
waters. Again, some feminists have attempted to buttress the Kantian notion of '
autonomous decision by providing nuances that recognize the influence of oppression on

“rational” choices. For example, the distinction between procedural autonomy and

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substantive autonomy is one attempt to retain a concept of rationality, while

Simultaneously recognizing the effect oppression has on rational decision-making. 29
Nonetheless, prolific work within the canon of feminist philosophy, particularly by
radical feminists and feminist historians of philosophy, has convincingly identified the
split between the autonomous rational ‘self’ and the nonrational dependent ‘other’ to be a
reflection and reinforcement of role expectations of men and women.

We see the classical concept of the liberal self woven throughout psychiatry,
particularly within standard theories in the psychology of personality to explain the
etiology of borderline. For example, object relations theory posits that the normal

“psychic structure [i.e. personality] is composed of units involving a representation of

self, a representation Of the other in relation to self, and an affect linking the two.”30

adaptation of Freudian psychology, object relations theory, posits that humans have an
innate drive to become autonomous subjects, through a process known as separation-
individuation, which then allows the mature person to enter into healthy relationships.
Representations of other people are “objects” and, as Greenberg and Mitchell describe,
object relations “designates theories, or aspects of theories, concerned with exploring the
relationship between real, external people and internal images and residues of relations
with them, and the significance of these residues for psychic functioning?“ The normal
personality structure is defined in terms of internal coherence, a recognition of the
separation of the self and other, and,

...the capacity for mature interdependence characterized by deep

emotional commitments to others in the context of maintaining a sense of

autonomy... The mature system of internalized values, while rooted in

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parental values and prohibitions, does not remain rigidly tied to parental

prohibitions, but becomes a stable, individualized, internal structure that

exists independently of external relations with others.32
Becker has criticized Kemberg’s theory that borderline is caused by a short-circuiting of
object relations for being little more than a sophisticated version of Freudian Oedipal
theory. As a result, Becker says,
Pregenital—particularly oral—aggression is generally projected onto the
mother and, to a lesser extent, the father. The mother becomes, by this
means, a dangerous and potentially destructive object, and the father
gradually also becomes a screen for aggressive projection... The
borderline individual, in Kemberg’s scheme, remains developmentally

arrested at the stage of early object relations where representations Of self

and other remain unintegrated.33
The stunted development of a fully integrated superego and ‘identity diffusion’
eventually cause the ego to resort to the primitive defenses that characterize the
borderline patient’s symptomatic inability to maintain healthy relationships. Often, it is
claimed, these primitive defenses involve deceit and manipulation of others. Though not
an explicit criteria in the DSM, manipulative behavior by borderline patients is a typical
symptom. The borderline patient is said to manipulate everyone She encounters. She
manipulates her therapist, as we saw, through the process of transference, which is said to
undermine all efforts by the therapist to treat the borderline patient. As a result of their
penchant for manipulation and transference, according to the standard construction the

borderline patient is seen as tragically incurable. As Kemberg says,

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regression within a psychoanalytic treatment, not only because of their ego
weakness and their proneness to develop transference psychosis, but also,
and very predominantly, because the acting out of their instinctual
conflicts within the transference gratifies their pathological needs and
blocks further analytic progress... Efforts to treat these patients with
supportive psychotherapy frequently fail.34
Within the diagnostic explanations of manipulation, lying, and deception, we begin to see
judgments about personal morality built into the signs and symptoms of the borderline
disorder. As Clarkin, et al. explain, “Low level borderlines are relatively lacking in

internalized moral values, at the extreme manifesting borderline and antisocial behavior

Without feelings of fear of wrong and guilt.”35 Thus, an inevitable question finally comes
to the fore: Is the borderline woman inherently immoral? As we know, the borderline
personality, according to the standard construction, is a fragmented and stunted version of
the coherent rational self. This results in an erosion of the governance and self-
management by the superego, which prevents the borderline person from apprOpIiately
relating to others. Therefore, as a dependent individual who is fated to a life of
heteronomy, the borderline woman is utterly morally flawed.

To answer some of the above concerns, researchers continue to work to more
Objectively assess the borderline disorder using psychometric research to refine the
current taxonomy (i.e. in preparation for yet-to-be published DSM-W. Weston and
Shedler, for example, admit that the “diagnostic categories [of personality disorders] have

their origins in clinical observation and theory. . .[h]owever, they have truly satisfied

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neither researchers nor clinicians, including members of the DSM-IV task force
itself...”36 They have therefore worked to add more empirical evidence to the criteria for
determining personality disorders and developed psychmetric tests such as the Shedler—
Westen Assessment Procedure-200 (SWAP-200) to refocus the diagnostic around
dimensional prototypes of each disorder. But it is possible that these more sophisticated
research programs may actually rehash previous, more obviously biased, assessments.
For example, Table 1 presents a concatenation of several of the questions from the

SWAP, which I have categorized according to particular dimensions of the liberal

(or bias) that Winston-Cauchon and Kaplan have argued is characteristic of the overall
diagnosis. In each case, we find a particular assumption or combination of assumptions
about the idealized self, whether it is the independent and nonrelational self, the rational
self, or simply an ideal of a deferential person who accepts a power structure without
complaint. Although these items should not be analyzed as single empirical nodes, but
rather viewed holistically in the context of the entire constellation of behaviors, we do
find interesting examples of what feminists have identified as constituting potential
‘double binds’ across the individual items. For example, we see this dynamic reflected in
items related to relational volatility, emotional lability and irrationality typical of the
disorder defined in terms each other. Another item finds a potential symptom in women
Who are “ingratiating or submissive,” while at the same time, “a tendency to get into
Power struggles” is also considered symptomatic. Consequently many women become

ensnared in a diagnostic double bind.

One final anecdote on the power of words in diagnosis: the diagnostrc Intervrew

I91

Kenneth Zucker pointed out:
Summary statement 25 [of the DIB] reads as follows: “[The patient]
actively seeks a relationship taking care of others (e. g., nurse, veterinarian,
housekeeper)...” Since the patient can be either a man or a woman, it is
unclear why two of the three occupational examples (nurse and
housekeeper) are those predominantly populated by women. These
examples appear sexist in implying that borderline personality disorder
might be overrepresented among nurses. It is obvious why this occurred:
borderline personality disorder is diagnosed much more frequently in
women than in men. Nevertheless, a simple change in the phrasing (e.g.,
“health professional” instead of nurse) would render it nonsexist but retain

the underlying conceptual. point that people with borderline personality

disorder might be drawn to a profession that provides care to others.37
When terminology within the interview protocol reinforces latent biases of the standard
construction, it makes it all the more difficult for clinicians to recognize and examine
their own biases when diagnosing patients.

Indeed, despite the best efforts of DSM work groups, we find the fingerprints of
Enlightenment social, moral, and political ideals, transmitted through object relations
theory and codified in recent iterations of the DSM. Thus, to apply the pragmatic theory
toward the goal of a more ethically justifiable model of borderline disorder, we must

remain cognizant of how its historical, philosophical, and popular biases permeate the

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current category and potentially motivate research into the biological basis of the
disorder. Let us now consider how we might critically interpret data about the biological

basis of borderline.

193

Table 1. Selected items describing patients with borderline disorder or dysthymia
(including BPD patients) from the SWAP-200 assessment procedure, cross-referenced
to potential gender biases that are related to the liberal ideal of the self. (I = Failure of
the rational selfi 2: Failure of the individual self; 3 = Failure of deferential self)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

‘ cf" a" rat ' 6' iii” W“ t'éi 1’ " " " W... ....‘_.'Z. . .... .........i..... "i
Emotions tend to spiral out of control, leading to extremes of anxiety, sadness, I
rage, excitement, etc.

Tends to fear she/he will be rejected or abandoned by those who are emotionally 1, 2
significant.

ls unable to soothe or comfort self when distressed; requires involvement of 1, 2
another person to help regulate affect.

Tends to be angry or hostile (whether consciously or unconsciously). 1
Tends to feel she/he is inadequate, inferior, or a failure. 1
Tends to feel misunderstood, mistreated, or victimized. 1, 2
Tends to become irrational when strong emotions are stirred up; may show a 1
noticeable decline from customary level of functioning.

Lacks a stable image of who she/he is or would like to become (e.g., attitudes, 1
values, goals, and feelings about self may be unstable and changing).
Tends to be overly needy or dependent; requires excessive reassurance or I, 2
approval.
Tends to act impulsively, without regard for consequences. 1
Is simultaneously needy of, and rejecting toward, others (e.g., craves intimacy 1, 2
and caring but tends to reject it when offered).
Tends to express intense and inappropriate anger, out of proportion to the 1
situation at hand.
Tends to “catastrophize”; is prone to see problems as disastrous, insolvable, etc. I
Tends to feel helpless, powerless, or at the mercy of forces outside his/her 1, 2
control.

Interpersonal relationships tend to be unstable, chaotic, and rapidly changing. 1, 2
Tends to feel like an outcast or outsider; feels as if she/he does not truly belong. 1, 2
Tends to become attached quickly or intensely; develops feelings, expectations, 1, 2
etc.. that are not warranted b the histo or context of the relationshi .
‘ at" " ' ‘ ' " " '36 s" vi‘itli'B . 1'.“ .1; ‘ . ‘

fl; ingratiating or submissive. 2
Dpscribed a tendency to get into power struggles 3
Iggds to be angry or hostile. I
Tends to blame others for their own failures or shortcomings; to feel 1,2,3
misunderstood, mistreated, or victimized.

Igpds to be oppositional and contrary. 3
Eggs to feel helpless or powerless. . I, 3
1311M be suggestible or easily influenced. I, 2, 3
339m be overly needy or dependent. 1, 2
Iglldyo fear they will be rejected or abandoned. I, 2
[ends to fear being alone. 1, 2

 

 

 

194

Biological Function & Borderline
A key feature of the pragmatic-ethical theory of mental disorder is that it requires

a critical examination of our categories of boundary cases to expose latent and ethically
problematic biases. Yet some might object that the above critical discussion of borderline
offers nothing more than an historical account of a mislabeling of symptoms of mental
disorder, which has now been superseded and corrected by reliable empirical evidence.
They might support a modified version of the standard construction by arguing that
borderline is now more clearly based on evidence of biological dysfunction. Those who
make this argument would marshal recent neuropsychological evidence to claim that
borderline is fundamentally a set of brain-based dysfunctions that are common across all
those who suffer from the disorder.

Such a move would in fact shift attention away from the long-standing definition
of personality disorder, which is explicitly based on socio-cultural functioning. Likewise,
this kind of objection is a derivative of the more general debate regarding the ontological
nature of the concepts of health, disease, and illness. As we already discussed, naturalists
such as Boorse argue disease is reducible to biological dysfunction. His biostatistical
theory of disease relies on the standard of species typical functioning, against which
measurements of dysfunction should be made. Functional assessments are, to Boorse,
value-free empirical tallies. In the case of borderline, some argue, evidence of abnormal
brain activity and morphology is now available. Therefore, it seems, we can avoid '

questions about past or present biases or ideological influences by strengthening

borderline’s standard construction with more and more neurological data.

195

However, such an approach is a self-fulfilling prophecy. The empirical data
related to abnormal biological function assume a standard of species typicality with
respect to the constellations of behaviors in question, which, at least to my knowledge,
has yet to be assembled. Moreover, because the definitions of personality disorders are
couched in deviations from cultural expectations, the search for a biological basis of such
deviations simply ignores the possibility that those expectations are themselves
problematic. We see this tendency implicitly across recent correlation studies, which are
interpreted as providing causal evidence of borderline’s etiology. These studies suggest

borderline is directly related to genetic predispositions, metabolic and endocrine

disorders, and abnormalities in brain morphology and brain lesions.40
In one more recent study, Evardone, et al. point out that particular hormone levels
are correlated to symptoms of borderline personality. Their results indicated that
“measures of hormonal change from week 1 to week 2 of the menstrual cycle, a time of
follicular development and increasing estrogen levels, were associated with higher
symptoms scores” associated with the borderline disorder.41 They also cite recent
evidence that borderline personality is associated with altered brain morphology in
systems for emotional processing and executive fimctioning. Several twin studies also
seem to point to a genetic basis and heritability for borderline.42
I certainly accept that biomedical research is critical and valuable in assessing the
status of the borderline disorder. To deny a biological basis or predilection for various
components of the borderline disorder would be naive and would fly in the face of i
compelling scientific research that links both genetic and physiological factors to core

cases of mental illness. However, as we work from a critical feminist perspective—in our

196

effort to apply the pragmatic theory ethically—scientific data suggesting a
straightforward biological basis for the complex characteristics of borderline should give
us pause. Again this is not to deny the potential biological basis of borderline, but rather
to cast a critical eye on the sociopolitical dimensions that might influence the researchers,
study design, and the scientific enterprise more broadly. Provided the historical and
social dimensions of borderline we have reviewed, as well as the compelling literature on
the social and political dimension of science itself, a pragmatic ascription of borderline
that invokes correlation data must be made cautiously.

In addition to remaining cognizant of the historical legacy of borderline, another
cautious tack would entail recognizing that the constellations of behaviors that make up
borderline represent a set of irreducible and complex interactions between social and
biological factors, which are constantly in flux. This should not come as a surprise nor
do I believe it to be a radically groundbreaking insight; many mental illnesses emerge
from the nexus of social expectations and biological bases of behaviors. What is unique
in our pragmatic analysis of borderline is the way in which we can apply feminist
methodology to reveal this disorder’s social, political and ethical dimensions before
deciding how best to recast those behaviors as disordered or not. For a pragmatic
reconstruction of borderline to meet ethical muster, we must acknowledge ideological
presuppositions and potential biases and seek to minimize their influence on the

reconstruction of the category.

I97

 

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Stigma

In addition to the conceptual feedback loop caused by correlation data, there exist
other amplifiers of the standard construction caused by the diagnostic habits and
misunderstandings of individual clinicians. Stigma is one such amplifier. According to

Goffman, stigma is defined as a physical or social attribute that diminishes a person’s

social identity and disqualifies her fiill social acceptance.43 Stigma represents the
differentiation of normal and abnormal, in-group and out-group, and imputes, by
definition, a negative view of those who are stigmatized. In presenting his theory of
stigma, sociologist Erving Goffrnan states:
The attitudes we normal’s have toward a person with a stigma, and the
actions we take in regard to him, are well known, since these responses are
what benevolent social action is designed to soften and ameliorate. By
definition, of course, we believe the person with a stigma is not quite
human. On this assumption we exercise varieties of discrimination,
through which we effectively, if often unthinkingly, reduce his life
chances. We construct a stigma-theory, an ideology to explain his
inferiority and account for the danger he represents, sometimes
rationalizing an animosity based on other differences.“
Stigma is, of course, associated with most mental illnesses. But the kind of stigma
experienced by patients with personality disorders may have a unique impact, because it
exacerbates the very behaviors that generate the stigma. It is now well known that a
diagnosis of borderline represents a ‘red flag’ in the patient’s medical history, warning

other clinicians and future therapists of the patient’ 3 troubled past and potential

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therapeutic challenges. A study by Aviram, et al. shows that therapists react more
negatively to cases in which a prior diagnosis of borderline had been made.45 In the case
of borderline, the term ‘borderline’ has shifted back into metaphoric usage, to single out
the prototype of the difficult, incorrigibly disturbed (often female) patient. Goffinan
describes this dimension of stigma stating, “We use stigma terms such as cripple, bastard,

moron in our daily discourse as a source of metaphor and imagery, typically without

giving thought to the original meaning.”46 The influence of the metaphorical and
stereotypical portrayals of the borderline patient, in combination with the actual
behaviors of the patient, will oftentimes cause a therapist to recoil. As Aviram, et al.
have found, such a response may worsen the patient’s condition by exacerbating the
stigma and alienation that the patient experiences.

Additionally, as is the case with most stigmatized people, patients with borderline
disorder may initiate strategies of “stigma management” to minimize the negative effects
of stigma to compensate for or camouflage their abnormality. Management strategies
might include behaviors that the clinician interprets as disingenuous, manipulative, or as
evidence of an identity disturbance. In a frantic effort to minimize her stigmatized image,
the borderline patient redoubles her coping strategies by employing the same
dysfimctional behaviors that were the kernel of the problem. Aviram, et al. summarizes
the cycle of stigma according to four stages: borderline behaviors of self-injury and

withdrawal, the confirmation of stigma, the therapist’s emotional distancing, which leads

then to further self-loathing, which results in more behavioral dysregulation.47
Insights related to the negative impact of stigma created by the diagnosis of

borderline might be construed as part of the argument for its demedicalization or

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dropping the disorder entirely from the official nosology. It would be a mistake however
to interpret these troubling findings about stigma as the final word on the pragmatic
ascription of disorder to borderline. As I will now discuss, stigma is a manageable side
effect in the otherwise appropriate treatment of borderline as a medical disorder and can
be mitigated if in our reconstruction of the category we are cognizant of the stereotypes
of borderline. For example, one place to minimize the effects of stigma would be among
clinical professionals themselves. Providing them with educational information about
newer, more effective therapies and by cultivating several of the aforementioned virtues
that aim to provide clinicians an array of intra and interpersonal resources should help
them more constructively work with persons who have borderline disorder. Let us now

turn to my proposed way to reconstruct the borderline disorder.

Conclusion
In this chapter, I tried to do several things, all aimed at applying key facets of my

proposed ethical pragmatic theory of disorder to borderline. First, I provided the reader
with historical background on borderline to help ascertain the disorder’s problematic past.
I have argued the historical construction of borderline has failed to meet the ethical
standards I set out for an appropriate pragmatic ascription of disorder. Thus, the standard
construction of borderline serves as an anti-paradigm of how the pragmatic theory should
be applied. Specifically, the standard construction, as it has been illustrated and amplified
throughout its history and in popular portrayals is an instantiation of socio-political .

oppressive and gendered norms that have inappropriately been applied to various

behaviors clustered within the concept of ‘borderline.’ These norms, in turn, are deeply

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rooted in the central constructs of liberal philosophy. Let us now apply these insights as
we begin an ethical—pragmatic reconstruction of the classification, diagnosis, and

treatment dimensions of borderline personality disorder.

 

1. Janet Wirth-Cauchon, Women and Borderline Personality Disorder: Symptoms and Stories

(New Brunswick: Rutgers University Press, 2001).; Nancy Potter, Mapping the Edges and the In-between:
A Critical Analysis of Borderline Personality Disorder ( New York: Oxford University Press, 2009).

2. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 41"
ed., text rev. (Arlington, VA: American Psychiatric Publishing, Inc.) “Diagnostic criteria for 301.83
Borderline Personality Disorder: A pervasive pattern of instability of interpersonal relationships, self-
image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of
contexts, as indicated by five (or more) of the following: ( l) frantic efforts to avoid real or imagined
abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion S; (2) a pattern
of unstable and intense interpersonal relationships characterized by alternating between extremes of
idealization and devaluation; (3) identity disturbance: markedly and persistently unstable self-image or
sense of self; (4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,
substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior
covered in Criterion 5; (5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior; (6)
affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or
anxiety usually lasting a few hours and only rarely more than a few days); (7) chronic feelings of
emptiness; (8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper,
constant anger, recurrent physical tights); (9) transient, stress-related paranoid ideation or severe
dissociative symptoms.”(10.l l76.appi.books.9780890423349.383 l)

3. John G. Gunderson, Borderline Personality Disorder (Washington, DC: American Psychiatric
Press, 1984), 1 1-18; Joseph Deltito, L. Martin, J. Riefkohl, B. Austria, A. Kissilenko, P. Corless, and C.
Morse, “Do Patients With Borderline Personality Disorder Belong To The Bipolar Spectrum?” Journal of

Aflective Disorders. 67, no. I (200]): 221-228.
4. Wirth-Cauchon, 2001, 41; Andrew Wynter, The Borderlands of Insanity and Other Allied

Papers (New York: G. P. Putnam's Sons, 1875).
5. James C owles Prichard, A Treatise on Insanity and Other Disorders Aflecting the Mind

(Philadelphia, PA: E.L. Carey & A. Hart, 1837).
6. Wirth-Cauchon, 2001, 3; Adolf Stern, “Transference in Borderline Neuroses,” Psychoanalytic

Quarterly 17, no. 4 (l948):527-528.
7. John G. Gunderson, “Borderline Personality Disorder: Ontogeny of a Diagnosis,” American

Journal of Psychiatry 166, no.5 (2009):530~539.
8. Otto Kemberg, Borderline Conditions and Pathological Narcissism (New York: Jason

Aronson, 1975), I3.

9. Otto Kemberg, Borderline Conditions and Pathological Narcissism, (New York: J. Aronson,
1965), 14.

IO. lbid., 15.

ll. lbid., 61.
12. Gerald Klerman, “Historical Perspectives on Contemporary Schools of Psychopathology,” in

Contemporary Directions in Psychopathology: Toward the DSM-IV ed. Theodore Millon and Gerald L.
Klerman (New York: Guilford Press, 1986) 3-28; A complementary account of the evolution of the DSM-
Ill comes by way of Nassir Ghaemi who argues that Karl Jaspers’s critical work on Kraepelin had an
equally important impact on the manual. Though Jaspers was critical of Kraepelin’s reductionism, he
agreed that a nosological structure was needed for psychiatry, and that this structure should recognize the
Complexity of psychiatric conditions. Jaspers likened psycho-nosology to botony—where it was quite easy
to describe the characteristics of individual species of plants, but much more difficult to describe the
concept of ‘plant’ itself. Thus, as Ghaemi suggests, Jaspers is “taking a stance here on the old philosophical
debate about the particular versus the universal, and saying we should stick with the particular.” Indeed,

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Jaspers presents a very pragmatic perspective in that he argues that psychiatric nosology is necessary for
grounding clinical interactions, treatment, and research. Jaspers even offered his own nosological
breakdown, which seems to be reflected in the DSM and 1CD that included three groups: Group 1, 'Known
somatic illnesses with psychic disturbances' (such as cerebral tumors, meningitis); Group II, 'The three
major psychoses' ('genuine epilepsy', schizophrenia, and manic-depressive illness); Group III is the
'Personality disorders'. See: S. Nassir Ghaemi, “Nosologomania: DSM & Karl Jaspers' Critique of
Kraepelin,” Philosophy, Ethics. and Humanities in Medicine 4, no. 10 (2009) doi:10.1186/1747-5341-4-10.

13. Eli Robins and Samuel B. Guze, “Establishment of Diagnostic Validity in Psychiatric Illness:
Its Application to Schizophrenia,” American Journal of Psychiatry 126 (1970): 983-987.

14. Laura S. Brown, “A Feminist Critique of the Personality Disorders,” in Personality and
Psychopathology: Feminist Reappraisals, ed. Laura S. Brown and Mary Ballou (New York: Guilford Press,

1992), 210.
15 . American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd

ed.(Washington, DC, American Psychiatric Association, 1980).

16. Gunderson, 1984, 6-7.
17. Mary C. Zanarini and Frances R. F rankenburg, “Pathways to the Development of Borderline

Personality Disorder,” Journal of Personality Disorders 11, no. 1(1997): 93-104.; Mary C. Zanarini, and
Frances R. Frankenburg, “The Essential Nature of Borderline Psychopathology” Journal of Personality

Disorders 21, no. 5(2007): 518-535.
18. Marcie Kaplan, 1983. “A Woman’s View of DSM-lll,”American Psychologist 38, no.

7(1983): 788-789.

19. Phyllis Rooney, “Gendered Reason: Sex Metaphor and Conceptions of Reason,” Hypatia 6,
no. 2 (1991): 86.

20. Wirth-Cauchon, 2001, 43.

21. Martin Leichtman, “Evolving Concepts of Borderline Personality Disorders.” Bulletin of the
Menninger Clinic 53, no. 3 (1989): 230.

22. Christine Ann Lawson, Understanding the Borderline Mother: Helping Her Children
Transcend the Intense, Unpredictable, and Volatile Relationship (New York: Rowman & Littlefreld

Publishers, Inc, 2002), 5.
23. Ibid, 30.
24.1bid, 142-143.
25. lbid., 37-38.

26. Rooney, I991, 91.
27. For example, Wirth-Cauchon cites the work of Danny Wedding and Mary Ann Boyd, whose

book, Movies and Mental Illness (1998), includes a case work-up of Alex Forrest (played by Glenn Close
in Fatal Attraction). Wirth-Cauchon argues both that the portrayal of borderline is deeply flawed and,

importantly, any lessons gleaned from this portrayal will overlook the basic context within which
borderline instantiates in the real world. To Wirth-Cauchon such representations ignore the most important

features of women’s experience of borderline and its underlying causes. Moreover, the portrayal of Forrest
as a ‘madwoman’ and Dan Gallagher (played by Michael Douglas) as the innocent victim reinforces the
legitimacy of a patriarchal power relation.

28. Joel Anderson and Axel Honneth, “Autonomy, Vulnerability, Recognition, and Justice”
Autonomy and the Challenges to Liberalism New Essays ed. John Christman and Joe] Anderson (New

York: Cambridge University Press, 2005), 128, italics in original.
29. For example, the distinction between procedural autonomy and substantive autonomy is one

attempt to retain a concept of the rational self, while recognizing the effect oppression has on rational
decision making. See Catriona Mackenzie and Natalie Stoljar, Relational Autonomy. Feminist Perspectives

on Autonomy, Agency, and the Social Self (Oxford. Oxford University Press, 2000).
30. John F. Clarkin, Mark F. Lenzenweger, Frank Yeomans, Kenneth N. Levy, and Otto Kemberg,

“ An Object Relations Model of Borderline Pathology. ” Journal of Personality Disorders 21, no 5(2007):

476.
31. Jay R. Greenberg, Stephen A. Mitchell, Object Relations in Psychoanalytic Theory

(Cambridge, MA: Harvard University Press, 1983), 12.
32. Ibid, 477, italics mine.

202

 

33. Dana Becker, Through the Looking Glass: Women and Borderline Personality Disorder

(Boulder, CO: Westview Press, 1997), 51-52.
34. Otto Kemberg, Borderline Conditions and Pathological Narcissism (New York: Jason

Aronson, 1974) , 71.

35. C larkin, et al., 2007, 483.
36. Drew Westen and Jonathan Shedler, “Revising and Assessing Axis II, Part II: Toward an

Empirically Based and Clinically Useful C lassification of Personality Disorders.” American Journal of

Psychiatry 156 (1999): 273—285.
37. Kenneth J. Zucker, “Sexism and Heterosexism in the Diagnostic Interview for Borderline

Patients?” American Journal of Psychiatry 153, no.7( l 996): 966.
38. Jonathan Shedler and Drew Westen, “The Shedler-Westen Assessment Procedure (SWAP):
Making Personality Diagnosis Clinically Meaningful.” Journal of Personality Assessment 89, no. 1(2007):

41-55.

39. Westen and Shedler, 1999.
40. José De la F uente, Serge Goldman, Etienne Stanus, Coro Vizuete, Ignacio Morlan, Julio

Bobes, and Julien Mendlewicz, “Brain Glucose Metabolism in Borderline Personality Disorder,” Journal
of Psychiatric Research 31, no. 5(1997): 531-541; Heather A. Berlin, Edmund T. Rolls, Susan D. lversen,
“Borderline Personality Disorder, Impulsivity, and the Orbitofrontal Cortex,” American Journal of

Psychiatry 162, (2005): 2360-23 73.
41. Milagros Evardone, Gerianne M. Alexander, and Leslie C. Morey, “Hormones and Borderline

Personality Features,” Personality and Individual Diflerences 44, no. 1(2007): 285.

42. Marijn A. Distel, Irene Rebollo-Mesa, Gonneke Willemsen, Catherine A. Derom, Timothy J.
Trull, Nicholas G. Martin, Dorret I. Boomsma, “Familial Resemblance of Borderline Personality Disorder
Features: Genetic or Cultural Transmission?” PLoS ONE 4, no. 4(2009): e5334.
doi:10. l 371/journal.pone.0005334; Despite their widespread use, twin study methods have been criticized
as unreliable because they provide no real environmental controls. See: Jay Joseph, “Twin Studies in
Psychiatry and Psychology: Science or Pseudoscience.” Psychiatric Quarterly 73 no.1 (2002): 71-82.

43. Erving Goffman, Stigma: Notes on the Management of Spoiled Identity (New York: Simon

and Schuster, 1963)

44. lbid, 5.
45. Ron B. Aviram, Beth S. Brodsky, and Barbara Stanley, “Borderline Personality Disorder,

Stigma, and Treatment Implications,” Harvard Review of Psychiatry 4, no. 5(2006): 249-256. The reasons
for this negative reaction are yet to be determined. One plausible explanation is that clinicians assume
personality disorders and borderline particularly are not mental disorders. Rather, they are personal failings
and problematic behaviors are not instances of symptoms but rather as “the patient’s choice to make an

interpersonal demand upon the clinician,” (250).
46. Goffman, 1963, 5.
47. Aviram, et a1, 2006, 252.

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CHAPTER 7
AN ETHICAL-PRAGMATIC RECONSTRUCTION OF
BORDERLINE PERSONALITY DISORDER (PART 11)
Introduction
To reconstruct borderline personality disorder according to our pragmatic theory
will require conceptual adjustments and ethical considerations be applied at each of the
key junctures of disorder-ascription that I described in chapter 5 alongside insights from
the critical analysis presented in chapter 6. Therefore, in this chapter, I will consider four
ways to refocus psychiatric and philosophical attention on borderline in a pragmatic
effort to offer a more ethically justifiable method to both classify and diagnose
constellations of behavior as disordered. This will in turn have a positive impact on the
efficacy of therapies designed to relieve the suffering experienced by borderline patients
and of those with whom she interacts.

First, in order to clarify and recognize the context of the suffering experienced by
those affected by borderline in a way that satisfies the proposed pragmatic-ethical
benchmarks, I will consider broad proposals to restructure the classification itself. One
possibility is to completely re-categorize borderline by interpreting its characteristic
socially dysfunctional behaviors as instances of manic impulsivity. Indeed, some have

suggested that subsuming the disorder under the larger spectra of bipolar or post-
traumatic stress disorders will help to minimize the disorder’s stigma and will facilitate
more efficacious kinds of therapeutic intervention. This is certainly one very attractive

pragmatic option that I will consider in some detail as I ask whether or not such a

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proposal firlfills the basic ethical principle of authentic beneficence (i.e. for whom would
such a reclassification primarily benefit: the patient, the clinician or the researcher?)

Second, I will describe how to recast symptoms in order to filter out biases that
seem to be latent in the way in which borderline behaviors are viewed and labeled. This
move is related, of course, to the first consideration, but will be more of a specific
treatment of particular symptoms of borderline. As I alluded to in the previous chapter, a
reconsideration of symptoms such as anger and manipulation through a more contextual
lens is an essential part of what I take to be an ethically justifiable pragmatic
reconstruction. I will therefore take time in this chapter to argue for an epistemic shift in
how we interpret specific habits that constitute the characteristic behavioral constellation
of borderline. In doing so, I hope to Show that the benefits of adjusting our
comprehension of specific symptoms will pay dividends in therapeutic efficacy, which
brings me to the third goal of this chapter.

I propose rethinking standard treatment modalities to recognize the historical and
ideological biases that have for so long hindered the development Of efficacious treatment
programs. To this end, the use and development of feminist and dialectal behavioral
therapies have been promising. Moreover, a key will be to develop therapeutic strategies
that help the borderline patient understand their anger is legitimate but misdirected. This
is to say, in the spirit of dialectical therapy, the pragmatic step will be to essentially coach
borderline patients to realign the focus of their anger toward constructive goals like
political activism. Psychoeducation with borderline patients is crucial to help them I

distinguish between legitimate targets of anger—such as oppressive social structures and

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people who support such structures—-—and other people who authentically desire to help
the patient with her difficulties.

Fourth, I will consider explicitly ways to recognize the far-reaching effects of
borderline on persons other than the patient. Drawing on ideas from systems therapy, I
will describe ways to protect the health and welfare of fiiends and family who try to help
those with the disorder and who are either directly hurt or suffer from collateral damage
caused by the disordered person. In this last section, I Offer thoughts on how to best treat
borderline while also keeping in mind the public health model of mental disorder, and
also considering controversial dimensions of that model (such as the possibility that it

would be coercive). Let us now look at each of these proposals in turn.

Reconsidering Classification

I hope I have provided enough background to show that the way in which the
borderline disorder has been historically constructed and metaphorically framed is
ethically problematic. We saw that both historical and narrative constructions of
borderline betray certain gender biases. Likewise, in some respects, psychometric and
neurological research tends to question-beg in the way borderline behaviors are defined
and assessed. In combination with the stigma-cycle, the standard construction of
borderline has a self-sustaining oppressive effect. Ultimately, biased diagnostic criteria
single out behaviors that deviate from the social norm, while simultaneously reinforcing
the oppressive structures that originally defined that norm. As I mentioned, some Will
argue that the above critical analysis supports the claim that borderline is a social artifact

produced by Oppression and, consequently, what needs to be fixed are the structures that

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create the context of the disorder. In other words, borderline disorder is not really a
‘disorder’, but, rather, it is an understandable set of responses and defensive behaviors
exhibited by those who are victimized by oppressive social structures.

Indeed, I fully acknowledge this point. It is not surprising that oppressive social
structures influence and stimulate compensatory behaviors by those in oppressed groups,
and that some of these behaviors can turn out to be problematic to both the oppressor and
the victim. In the case of borderline this seems to be the case as the criteria and

etiological evidence related to the disorder directly correspond to what Iris Young has

called the five faces of oppression.1 Specifically, the fear of violence, systemic economic
exploitation, and a sense of powerlessness all seem to predispose a woman to the
borderline disorder. Such structures often demand various borderline behaviors for
survival. Oppressive structures therefore might serve as incubators within which
precocious borderline women are formed. It therefore seems accurate to recognize
borderline behaviors among women as representing the sequelae of psychological injury
to the female psyche caused by oppressive social structures. In addition, it is the case that
a direct connection between abuse and borderline has been established. Such abuse might
come in the form Of physical violence by a parent, psychological threats, or a generally
toxic ambience within the family structure. Prolonged exposure to such psychological
insults will inevitably lead to some form of trauma and in many causes with chronic
stress. Indeed, recent data indicate borderline has about 30% comorbidity with PTSD.
With this in mind, I wish to point out a direction forward for reframing the ‘
classification and understanding Of borderline through Laura Brown’s concept of “Abuse

and Oppression Artifact” disorders. Brown proposes differentiating personality disorders

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to include “careful investigation of competing hypotheses such as gender-role

socialization, abuse experiences, and cultural Oppression prior to consideration of a

diagnosis of personality disorder.”2 Her theory encompasses the social context of
borderline behavior, paying particular attention to the patient’s history of abuse and sexist
social structures that create chronic stress. Similarly, as I will describe, feminist models
of psychotherapy attempt to integrate clear recognition of social and political position in
diagnosing and treating the borderline woman. Although the historical construction of
the disorder, recent tropes, and empirical research continue to problematize the borderline
disorder according to a gendered ideal of the self, these more recent trends toward
contextual treatment and understanding of the disorder are promising. This is one
promising avenue for the conceptual reexamination Of borderline.
Another possibility would be to reclassify borderline in terms of another mental

disorder. Some researchers have suggested considering borderline to be part of the

bipolar disorder spectrum. Noticing that bipolar and borderline are very often comorbid
conditions, and that many of the affect disturbances are common in both syndromes,

Smith, et al. have suggest that there is a strong case to be made for subsuming a

significant number of borderline patients under the rubric Of bipolar disease.3 The authors
articulate several pragmatic reasons for this move. One such reason reflects the fact that
the standard construction of borderline is difficult to treat because of transference and
countertransference. Inadvertent countertransference can be especially fraught because it
leads to an overreliance on treatment strategies such as pharrnacotherapy, which, as.
Valliant states, “if pursued tOO enthusiastically are more likely to lead to disaster than to

success.”4

208

Smith, et al. note that by reframing the difficult-to-treat behaviors as instances of
bipolar symptoms, clinicians will more easily treat patients without falling prey to
instances of countertransference. Moreover, they claim, such a redefinition of borderline
will spare the patient of the stigma of a ‘character disorder’ and replace it with a much
more manageable stigma of bipolar disease, which is more widely accepted as a true
mental illness. In sum, Smith, et al. suggest,

A reframing of borderline patients as suffering from a primary disorder of
mood is likely to hold potential benefits for patient and clinician alike. It
should reduce stigma and discrimination for patients, who can see
themselves as suffering fiom a valid psychiatric disorder instead of being
some way “flawed in character.” Similarly, clinicians can approach these
patients from new angles and apply treatment skills, both pharmacological
and psychological, already gained in the treatment of mood disorders.
Ultimately the hope is that such an approach would reduce the risk of

therapeutic nihilism in the care of this important and highly morbid group

of patients.5
This is indeed an attractive pragmatic solution to the problems associated with treating
borderline patients. But one must ask, would such a pragmatic revision meet the ethical
guidelines I have suggested? Is this pragmatic re-ascription rooted in a set of reasonably
sound ethical considerations? Is such a move motivated primarily for the benefit of
patients or for clinicians who have trouble mastering complicated treatment techniques

for borderlines?

209

Although it seems the authors wish to frame this move as a win-win for patients
and clinicians, it seems shortsighted in the way it simply uses a relabeling to avoid more
fundamental problems associated with the way in which the constellation of behaviors are
singled out. This is to say, what is more important in reconstructing borderline is figuring
out why we label borderline behaviors dysfunctional in the first place. The proposed
pragmatic move only reinforces the unspoken biases related to borderline disorder and
may in fact exacerbate these biases by forcing them deeper underground, masked under
the well established rubric of bipolar disorder. It is also curious that the authors think this
strategy will reduce the risk of therapeutic nihilism—or the tendency of clinicians to
believe nothing can be done for the patients. In a sense, the authors are calling for a
relabeling of borderline to trick clinicians out of their latent biases about borderlines,
instead of tackling the roots of those biases head on. I am thus dubious about this strategy
for philosophical reasons.

Others are skeptical as well. Psychiatrist Joel Paris argues that what Smith, et al.
suggest has no basis in psychological evidence. Borderline represents a distinct form of
disorder from bipolar—it is distinct in its etiology, phenomenology, and longitudinal
course, heritability, and treatment. Simply because there are similar symptoms across
bipolar and borderline does not justify coalescing the two categories. Paris points out
that, “in medicine, similar symptoms can have entirely different causes. Clinical

symptoms that resemble the mood changes seen in bipolar disorder may be no more

specific than fever or inflammation.”6 Thus, Smith, et al.’s proposal runs the risk Of

overlooking critically important dimensions of borderline while it also discourages

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research into borderline’s complex etiology, an examination of social and political
structures that may serve as incubators Of the disorder, and of possible therapies.

Suffice it to say, reframing the category of borderline requires a critical analysis
of the Oppressive factors that seem to play a role in the etiology of the disorder.
According to the ethical guideposts I set out in the chapter 5, the pragmatic theory
requires that the broader social forces that influence the category be factored explicitly
into the ascription or construction of the disorder. In contrast to Smith, et al., Brown
offers a more promising strategy for doing both. With Brown, the primary motivation is
to understand the classification of the disorder in a way that prioritizes the patient’s
experience, emphasizes clinician insight and uptake, and relies on trustworthiness and
beneficence. Thus, Brown’s strategy begins to satisfy our ethical considerations. The
strategy Offered by Smith et al. seems to be ethically deficient both in its questionable
motivation and because of doubts about whether it would actually work. Let us turn now
to see how Brown’s proposal might play out in the context of the symptoms of

manipulation and impulsivity.

Recasting Symptoms: Manipulation & Impulsivity

As we now know, closely associated with the above discussion about diagnostic
reconceptualization, is another important set of ethical-pragmatic steps toward
reconstructing borderline according our theory. These steps entail making an epistemic
shift in the way we come to know and understand each of the specific habits that
constitute the behavioral constellation of concern. In contrast to more acute symptoms of

borderline (suicidal behavior, self mutilation), several symptoms have been described by

. . ,,7 .
Zanarini, et al. as “temperamental symptoms. These tend to resolve slowly wrth

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therapy, if at all. Among the temperamental symptoms there are several that are
candidates for reappraisal according to a new ethical-pragmatic critical analysis. For
example, a more robust contextual examination is needed when considering the
symptomatic features of anger and manipulation, which we know marked features of the
borderline patient. As Nancy Potter suggests, the claim that the borderline woman is
manipulative relies on a particular assumption about the freedom, opportunity, and the
classical concepts of autonomy and the ideal self, which I described above. She suggests
the clinical observation that a borderline woman is manipulative often ignores the
context, out of which such behavior is necessary:

When someone aches for relationship and connection but characteristically

behaves in ways that prevent that person from sustaining them, the

behavior is dysfirnctional with respect to a vital human need. But I can

also imagine a defense of behavior that is manipulative, for direct access

to power and voice are not equally available to all of us, and manipulation

may be a survival skill.8
In such cases, lying and deceit may be an unfortunate learned response that is the
byproduct of abuse, neglect, or ambient oppression. Perhaps such behavior is an acute
defensive reaction to yet another asymmetrical power structure—the therapist-patient
dyad—of which the borderline woman is now a (lesser) part. By recasting the symptoms
of anger and manipulation in this critical way, we may advance our reconstruction of
borderline and avoid the temptation to simply ‘classify away’ evidence of deeper Social
and political injustices.

The symptoms included within the rubric of ‘impulsivity’ provide another

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interesting case study whereby negative meaning is attached to behaviors that are
haphazardly construed as irrational, dysfunctional and self—destructive. As a category of
symptoms, ‘impulsivity’ is a blunt instrument used to describe a wide array of behaviors
among borderlines from drug and alcohol use to shopping to sexual behavior. One way
in which this symptom category seems to be problematic is that it robs patients of
freedom to live with any amount of spontaneity lest they be judged as impulsive and
irrational. Thus, to more carefully refine how behaviors considered to be impulsive are
understood, it is first important to try to distinguish between spontaneous behaviors and
impulsive ones. One way to distinguish the two would be to understand the value
associated with each kind of behavior; Potter explains why and how impulsive behaviors
are considered negative while spontaneous behaviors are thought to be good.

Employing insights from Lee Brown, Potter illustrates the goodness of
spontaneity using the example of jazz music. The jazz musician produces music through
improvisation; but this improvisation is part of a larger meaning of the musical genre
itself. Moreover, the jazz musician is “self-monitoring”, meaning he is gifted with the
intuition and insight to know how to produce in the right time the sounds that make the
improvisation successful and pleasing to listeners. This is to say the jazz musician,

although improvising from moment to moment, “does so through deliberation and action

[that is] situated within larger plans and aims.”9 Potter distinguishes this from those who
act impulsively using the ‘Olaf Principle’, a term coined by Lynne McF all, which refers
to the character of a poem by e.e. cummings who resists succumbing to physical tOrture
as a contentious objector. The key point of the Olaf Principle is that there are certain

commitments in our lives that we would be willing to part with and that are less

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important to us than other things. However, there are other things that are much more
important to us; they are ‘identity-confen'ing’ or higher order commitments. These
commitments define one’s sense of self and should be indefeasible. Impulsive individuals
however, uncontrollably compromise these commitments, which results in shame as well
as in further erosion of the person’s sense of self. Both shame and the erosions of one’s
sense of self ultimately cause more profound suffering and distress.

The symptom of impulsivity is especially germane when discussing women’s
sexuality vis-a-vis borderline. As Potter suggests, the rote application of the concept of
impulsivity to women’s sexual behavior belies gendered expectations—that a woman
who engages in casual sex is impulsive, slutty, or whorish. Potter explains that such
behavior needs to be understood in terms of the Olaf Principle by asking, “Are these
women violating their own higher order standards of behavior and integrity and, if so,
why?”

Potter admits one risk in this kind of analysis is that it shifts us back into the
debate about whether the behaviors are signs of mental illness or vice—which I argued in
chapter 4 is an impractical and ultimately unproductive debate. This juncture of the case
analysis provides an opportunity to both reiterate and strengthen the pragmatic argument,
by using borderline impulsivity as an example of how difficult it can be to clearly parse
the behaviors in terms of the distinction between ‘mad’ and ‘bad.’ In other words, the
attempt to try to figure out the true nature of impulsivity—that is, whether or not
impulses are in some way volitional and thus less deserving of the ascription ‘disorder’—
is somewhat of a red herring, at least from a pragmatic perspective. It distracts us from

the ethical-pragmatic motivation of relieving suffering, which I have argued should

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remain primary to how we understand socially dysfunctional behaviors. Therefore, in the
case of impulsivity, the question of volition vis-c‘r-vr's impulsivity should be secondary to
the question of minimizing the harm caused by such impulsivity. It might turn out that
appealing to the borderline patient’s sense of free will, particularly if she can be shown
that such behaviors ultimately damage or diminish her freedom and life’s options, might
help her to control impulsive behaviors. If appealing to a patient’s free will turns out to
be helpfiil, then treating impulsivity as If it were volitional is the pragmatically justifiable
strategy. If, on the other hand, impulsive symptoms seem to be more effectively
managed by treating them as if they are caused by a brain-based disorder, then appealing
to the medical disorder as the cause is more justifiable. Thus what I am proposing is that
the ‘mad’ vs. ‘bad’ distinction be used in whatever way possible to minimize the
suffering cause by borderline impulsivity, regardless of the true nature of that
impulsivity.

In addition to this pragmatic reappraisal of the mad v. bad debate with relation to
impulsivity, l have one final concern with the Olaf Principle, which I should briefly
mention. It seems to me is that it is very difficult to disentangle the individual’s genuine
wishes (or first order commitments) from social expectations about what those
commitments ideally should be. This confusion may lead to questions about validity and
authenticity of the commitments described by the Olaf principle. Thus, we are back to the
original problem of wondering whether or not symptoms, such as impulsivity, are
reflections more of social expectations than of individual choice.

Nonetheless, despite these limitations, I think that recasting the symptom of

impulsivity against the contextual background proposed by Potter is an important step

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forward in our ethical-pragmatic reconstruction of borderline, because it helps to promote
a concept of impulsivity that is not dependent on potentially sexist expectations. Let us
now discuss how treatments might be reimagined to more adequately and ethically meet

our goal of minimizing the suffering caused by borderline personality disorder.

Rethinking Treatment: Dialectical Therapy & Uptake

Since the 1960’s there have been a plethora of published accounts detailing the
challenges often encountered when treating patients with borderline. Through personal
narratives, case studies and empirical research, therapists time and again have described
difficulties in their attempts to significantly alter the pervasively dysfunctional habits of
borderline patients. As Gunderson notes, pejorative descriptors such as “frequent flyer,”

99 “

“help-rejecting complainers, egocentric,” and “irresponsible” are generously sprinkled
throughout the literature and clinical lexicon. One researcher referred to borderline

patients as “intractable, unruly” patients who used hospitals to escape from
responsibilities.10 Gunderson has articulated the key treatment dilemmas that are
encountered in treating borderline patients. These include:

. Dramatic fluctuations in phenomenology and psychological capacities will
challenge diagnostic certainty.

- Urgent appeals for an exclusive helping relationship will generate strong
countertransference responses, often involving rescue efforts that prove to be
inadequate.

. Treaters and others will have intense and distinct reactions, seeing the patient as a

deprived waif or as an angry bully.

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. Separation experiences (or decreased structure) will prompt behavioral (self-
harrn) and cognitive (psychotic-like) regressions.
. Neither psychoanalysis nor medication will help significantly and will often be
harmful.11
As described above, such therapeutic difficulties seem to be impervious to conventional
modalities. And over the past two decades, it has become clear that conventional
treatments such as cognitive behavioral therapy (CBT) or psychoanalysis seemed to fall
flat (or, worse, exacerbate symptoms) when dealing with the borderline disorder. CBT
seemed both theoretically and pragmatically ill-suited to critically examine the milieu of
oppression, empathically explore histories of abuse, and constructively prescribe action
plans for borderline patients. What was needed was a shift in the orientation of CBT to
more aptly address the issues that left borderline patients languishing in a treatment
program built on a form of prescriptive rational thinking that further alienated
borderlines.

Marsha Linehan’s dialectical behavioral therapy (DBT) has sought to overhaul the
standard CBT model by augmenting it with features that enable the therapist to address
these more complex symptoms of the borderline patient.12 The methods of DBT depart
from conventional CBT in its shift away from overt change-oriented interventions to
acceptance and validation interventions. The dialectical relationship between acceptance
and change creates a stronger, more constructive relationship between the client and
therapist, which provides the needed foundation for long-term work. The key aspect of
DBT is strategic acceptance and validation of the concerns of borderline patients—which

had so often been discounted and marginalized as the ravings of a hysteric. Thus, DBT

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provides a structure for the concepts of uptake that and world travel described in the
chapter 5.
Indeed, DBT’s emphasis on acceptance and validation is reflective of the feminist

intuition, which is the claim that norms of femininity influence expectations and enhance

the oppression, making critical decisions women make “nonautonomous.”l3 Feminist
therapeutic approaches are well-equipped to provide the critical perspective and systems-
based approach to therapy. These approaches are varied and diverse, much like their
philosophical counterparts, and range from liberal feminist techniques, which aim toward
individual actualization and self fulfillment, to radical feminist therapy that emphasizes
the therapeutic potential (and moral calling) of political activism. They appeal to the
feminist consciousness, which is defined as the “awareness that one’s own suffering
arises not from individual deficits but rather from the ways in which one has been

systemically invalidated, excluded, and silenced because of one’s status as a member of a

nondominant group in the culture.”14

All of these approaches share the common features that dovetail with our
pragmatic ethical approach to both ascribing and treating the borderline disorder. They
recognize that personal “issues” are in part reflections of political realities. They demand
therapists have a deeper understanding of the oppressive socio-political factors that may
have caused or continue to enhance the disorder. Feminist methods of therapy for trauma
victims also meet these treatment standards. For example, Laura Brown proposes several
important features of feminist therapeutic techniques for treating trauma. Key features
such as recognition that the client should not simply be ‘healed’ but also empowered to

recognize and work to change the forces of marginalization, oppression, and abuse: “it is

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insufficient to treat one client and return that person to a world in which her or his trauma
will continue to occur unchecked.”1 5

Linking up the pragmatic theory of disorder with new, more effective treatments
of borderline disorder—through a recognition of the subjective experiences of the client,
the unique social contexts, and, importantly, the limits of conventional therapy—should
help clinicians cultivate therapeutic insight to more ably provide uptake and subsequent
relief to suffering clients. This is resonated by Potter, who encourages clinicians toward
‘epistemic humility’ and understands that:

...clinicians can, and should, think critically about ways in which

prevailing norms and values may be influencing their understanding of the

world and their ways of being in it. They need to be on guard against

subtle assumptions about health, rationality, and good actions that could

be misguided in the case of a particular patient and thereby inhibit that

patient's ability to hear.”16

These are just a few insights related to new forms of treatment that might support a
reconstructed version of borderline. Let us take a very brief look at one final set of
methods that recognizes the impact of borderline on families, friends, and the larger

community.

Recognizing Public Health Risks: Systems Therapies

Recall one constitutive element of the pragmatic version of a personality disorder
was recognizing its negative impact on others. As I described in Chapter 4, the public
health model can be aptly applied to borderline disorder not as a direct analogy but as a

heuristic that offers guidance on how to structure and deploy systematic interventions for

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the good of the broader community. The value of such an approach is recognized in
cases of antisocial personality disorder or psychopathy. Social structures that aim to
protect the community from the damage of persons with such disorders are ubiquitous-—
from legal protections and the criminal justice system to less formal personality
assessment regimes that seek to weed out troubled individuals from the ranks of
employees, the armed services, the clergy, etc. The very legitimate concerns about the
effectiveness or ethical legitimacy of these structures are afield from my main point here,
which is simply to say that the importance of public health interventions for serious
mental disorders seems reasonable. In the case of borderline, as I had mentioned its
public health dimensions remain largely unexplored, despite evidence that it has far
reaching implications on families, places of employment, and the community more
generally. Therefore, in our reconstruction of the disorder, these insights must be more
carefully examined, keeping in mind, again the latent power structures that might
illegitimately signify borderline as aberrant.

In any case, as with refinements to its classification, methods to treat borderline
disorder ought to also address its impact on the larger community. There are several
therapeutic options to mitigate the impact of borderline on nonpatients. One such
strategy, group skills training, is integrated into DBT. Surprisingly, there is very little
research into specific systems therapies (family therapy) for borderline patients and their
families. As Hoffman, et al. explain, there are now several family therapy methods

developed specifically to treat the impact of a particular disorder suffered by one Or more

members of the family.17 Methods of family therapy for anorexia nervosa, bipolar

disorder, schizophrenia, and addiction are now widely available. Successful strategies

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include meetings of multiple families, bringing together large groups of people who are
adversely affected by the mental illness of family members. But, despite a growing
number of patients with borderline, no such systematic strategies currently exist for them
or their families.

A few models do exist that seem promising. The first is Dialectical Behavior
Therapy-Family Skills Training (DBT-FST) with or without multiple families as
described by Hoffman, et al. The first key element of DBT-FST is psychoeducation,
which entails providing family members the background to help them understand the
clinical dimensions of the troubling behaviors of their family member. The second goal
is to teach family members a new, less confrontational vocabulary with which to
communicate about problem behaviors. The third goal is to teach both patients and
family members to be less judgmental of one another by accepting the central tenet of
DBT-——that there is no ‘absolute’ truth. Finally, the fourth goal, which seems prior to the
other three, is to provide the family a safe place to discuss extraordinarily difficult issues
openly.

Assertive community therapy (ACT) is an approach that provides the severely
mentally ill with individualized treatment and rehabilitation regimes that aim specifically
toward providing patients with the stability to live independently and become (and stay)
employed. Although costly, studies indicate that programs of ACT (PACT) are cost-
effective, reducing the duration of in-patient hospitalization.l8 One PACT client has
described his experience in the following way:

One of the good features of PACT is that people have ongoing care that

provides stability and continuity in their lives. And the care provided by

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the staff can mean a break and a relief for the family; no longer do
families have to be the treaters. Instead they can live their lives knowing
their loved one is being treated, and that cases the stress and strain on
families. For the most part, families are a part of the treatment team at
PACT. They are listened to and are respected by the program. This
community-based program, in my thinking, is another word for hope. It
isn‘t perfect. But for now, PACT—even after some 25+ years—is still an
innovative idea. With time and hard work there will be more PACTs out
there with more and more people getting good quality community
treatment.”

NAMI has endorsed ACT and has stated that one of its goals is “to make high quality

ACT teams available to all who need them and to educate others about the effectiveness

of this model.”20

I should mention here that ACT programs are not without controversy. One critic
of ACT, Tomi Gomory, channels Szasz in his vigorous challenge of ACT as being both
coercive and legitimized by a steady stream of invalid (i.e. tautological) outcomes
findings. Using historical evidence from the development of ACT at the Mendota State
Hospital in Wisconsin, Gomory argues that the ACT model,

is innately coercive and rests on a view of mental health patients held by

its developers as aggressive, willful actors who use various ‘weapons of

insanity’... ACT clients are forced by aggressive workers to comply

involuntarily with program demands and this activity results tautologically

in the misattribution of worker behavior for that of the client (i.e., client is

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forced to show up at an employment site and is ‘helped’ to stay there,
which is then counted as a day spent by the client in voluntary
employment for the purpose of ACT validation)... In a coercive climate,

forced or imposed client change is passed off as internalized or learned

client change.21
Additionally, Gormory argues that in most outcomes studies, hospitalization in-take
procedures had been modified for patients receiving ACT. Thus, cost-saving estimates
are wrong.

Gormory’s strong criticism of ACT does not invalidate its potential as a
promising intervention in a public health effort to mitigate the ill-effects of borderline
personality disorder. But it does remind us of the problems of medical over-involvement
especially in cases where the public health hazards are much less clear than cases of
disease outbreaks. Nonetheless, demand for family and community based interventions
for severe mental illnesses have increased dramatically. In response, organizations like
NAMI have developed a variety of programs. For example, NAMI’s Family-to-Family
program is a 12—week peer-led support class that aims to empower family members of
mentally ill persons with psychoeducation and provides them skills to more ably manage
the stress of caregiving or the contentious relationship they might have with their
mentally ill family member. Qualitative outcomes data seem to indicate that such
programs offer a unique benefit by helping family members shift their understanding of

mental illness and begin to implement healthier coping skills, enhancing their

communication and reducing anger.22 In the next chapter, I will discuss how such

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programs might be integrated into a larger policy framework for patients, family, and

other caregivers.

Conclusion

To reconstruct the concept of borderline personality disorder, I argued first in
chapter 6 that its historical construction be reconsidered according to the critical
theoretical standards I proposed in chapter 5. Similarly, the symptoms of borderline need
to be recast so that they are understood contextually, and not simply as isolated incidents
akin to hysterical outbursts or in terms of colloquial understandings of manipulation,
lying, and impulsivity. I provided a few thumbnails of treatment modalities that seem to
meet the standards I have endorsed in my ethical subtheories. These included a shift
away from change-oriented therapies like CBT to acceptance and validation oriented
therapies such as Linehan’s DBT. Supporting this move are the philosophical insights of
feminist philosophers and therapists who have developed models of therapy that aim to
engender empowerment, meaning and political activism among their clients. To address
the reality that borderline presents as a problem for families and the public, I have offered
two potential interventions that seem promising. Notwithstanding drawbacks, both DBT-
F ST and PACT may help to fill the current void of specialized systems therapies for
borderline disorder. Such approaches fit into the pragmatic theory because they
recognize the adverse affect of the disorder on the broader community, while they also

aim to help client-patients establish and maintain stable and productive lives.

_

I. Iris M. Young, Justice and the Politics of Diflerence (Princeton: Princeton University Press,
1990)

224

 

2. Laura S. Brown, “A Feminist Critique of the Personality Disorders,” in Personality and
Psychopathology: Feminist Reappraisals ed. Laura S. Brown and Mary Ballou (New York: Guilford Press,
1992), 220.

3. Daniel J. Smith, Walter Muir, and Douglas H. R. Blackwood, “Is Borderline Personality
Disorder Part of the Bipolar Spectrum?” Harvard Review of Psychiatry 12, no. 3 (2004): l33-I 39.

4. George E. Valliant, “The Beginning of Wisdom ls Never Calling a Patient a Borderline; or, The
Clinical Management of Immature Defenses in the Treatment of Individuals With Personality Disorders,”
Journal of Psychotherapy Practice and Research I (1992): I22.

5. Smith, et a1, 2004, 137.

6. Joel Paris, “Borderline or Bipolar? Distinguishing Borderline Personality Disorder from Bipolar
Spectrum Disorders,” Harvard Review of Psychiatry 12, no. 4 (2004): I42.

7. Mary C. Zanarini, Frances R. F rankenburg, John Hennen, Bradford Reich, Kenneth R. Silk,
“The McLean Study of Adult Development (M SAD): Overview and Implications of the First Six Years of
Prospective Follow—Up,” Journal of Personality Disorders 19, no. 5 (2005): 505-523.

8. Nancy N. Potter, “What is Manipulative Behavior, Anyway?” Journal of Personality Disorders
20, no. 2 (2006): 154.

9. Nancy N. Potter, Mapping the Edges and the ln-berween: A Critical Analysis of Borderline
Personality Disorder (New York: Oxford University Press, 2009)

10. Gunderson, 2009, 531.

ll. lbid., 533.

12. Marsha M. Linehan, Cognitive Behavioral Treatment of Borderline Personality Disorder.
(New York: Guilford Press, 1993).

13. Natalie Stoljar, “Autonomy and the Feminist Intuition” in Relational Autonomy: Feminist
Perspectives on Autonomy, Agency, and the Social Self ed. Catriona Mackenzie and Natalie Stoljar
(Oxford: Oxford University Press, 2000), 94-111.

14. Laura S. Brown, “Feminist Paradigms of Trauma Treatment.” Psychotherapy: Theory,
Research, Practice, Training 41, no. 4(2004): 464.

15. lbid., 470.

I6. Potter, 2006, 154.

17. Perry D. Hoffman, Alan F ruzzetti, and Charles Swenson, “Dialectical Behavior Therapy -
Family Skills Training,” Family Process 38 (1999): 399-414.

18. W.R. McFarlane, R.A. Dushay, P. Stastny, S.M. Deakins, and B. Link, “A Comparison of
Two Levels of Family-Aided Assertive Community Treatment,” in Families and Mental Health Treatment
ed. American Psychiatric Association (Washington, DC: Psychiatric Services Center of the American
Psychiatric Association, 1998).

19. National Alliance on Mental Illness, “PACT - A Client's Perspective,” http://bit.ly/aSDtC D
(shortened URL, accessed May, 2010)

20. National Alliance on Mental Illness, “Assertive Community Treatment (ACT),”
http://www.nami.org/Template.cfm?Section=ACT-TA_Center (accessed May 20l0).

21. Tomi Gomory, “The Origins of Coercion in Assertive Community Treatment: A Review of
Early Publications from the Special Treatment Unit of Mendota State Hospital,” Ethical Human Sciences
and Services 4, no.1(2002): 3-16.

22. National Alliance on Mental Illness, “Recent Studies of Family-to-Family,”
http://bitJy/aijnn (accessed June 2, 2010).

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CHAPTER 8

PRAGMATIC ASCRIPTIONS OF MENTAL DISORDER: POLICY CONSIDERATIONS

Introduction

In March 2010, while I was writing this dissertation, President Obama signed the
Patient Protection and Affordable Care Act (PPACA) into law. The PPACA will
dramatically alter the state of the US. healthcare system in the way patients are covered
by insurance providers, in the way health care is delivered, and (hopefully) in the way
costs are controlled. In this concluding chapter of my dissertation, I wish to briefly
discuss potential areas of intersection between my pragmatic theory of mental disorder
and key aspects of health care policy. The goal of this final chapter is relatively modest.
First, I will sketch a set of considerations for policymakers, patients, families, and others
affected by borderline personality disorder by first offering a brief critical analysis of the
current state of the disorder within the domain of public policy. In doing so, I will
critique the current political construction of the disorder and discuss ways to democratize
the process of diagnostic changes being currently considered for boundary cases.

Next, I will begin to discuss how a pragmatic theory of mental disorder might
inform two key questions. The first question concerns the potential need for reasonable
accommodations for persons with borderline. Because borderline is such a complex
disorder and is defined in terms of social dysfunction, the question of whether and how
the Americans with Disabilities Act covers it, for example, is vexing. Admittedly, this is
more of a legal question that is outside the scope of this dissertation; however, the

pragmatic goals of this dissertation make this a reasonable issue to begin to take up.

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The second question concerns improving access and treatment options for
borderline patients, their family members, or others secondarily affected by the disorder.
I will discuss potentially promising options that are implicitly or explicitly endorsed by
PPACA’s mental health care parity provisions, including specialty care medical homes. I
will not present exhaustive arguments or attempt to conclusively answer these questions.
Rather, I present these issues with an eye toward future research. Let us first begin by
discussing the place of personality disorders as a funding priority and in health policy

more generally.

Political Recognition, Participation, & Shifting Categories
It seems fitting that I began writing this chapter in May, which the National
Education Alliance for Borderline Personality Disorder designated as Borderline

Personality Disorder Awareness Month. The House of Representatives endorsed this

designation in HR. 1005, which was passed with unanimous support in April 2008.1
Representative Tom Davis (R-VA), who sponsored the resolution, said, “Mental health
professionals have recognized this disease since 1980, yet it continues to lag far behind
other psychiatric disorders of similar prevalence in research, treatment options and family
education. . .Raising awareness of this disease is an important first step toward getting the
recognition and research dollars that, hopefully, can help future victims and their families
avoid the enormous suffering this disease causes now.”2 Co-sponsor, Chris Van Hollen

(D-MD), echoed these sentiments, “Though it was officially recognized in 1980‘by the

psychiatric community, borderline personality disorder is at least two decades behind in

research, treatment options, and education compared to other major mental illnesses.” 3

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As the DSM-III had created and provided clinicians with an official label for
borderline, the House resolution provided the political imprimatur for broader recognition
of the disorder, encouraging further research, funding and policy development. This is
undoubtedly a good thing. But we must qualify our optimism and from a critical
pragmatic perspective we should ask the following questions: what motivated such
political recognition? Does such political recognition—as far as we can glean from HR.
1005 and subsequent policies—support a more ethically justifiable and pragmatically
advantageous understanding of borderline? Or does it reinforce flawed assumptions about
the disorder? In other words, will the current political recognition of borderline
personality disorder help to minimize suffering and reshape clinical efforts to treat the
disorder?

The Iawmakers’ statements and the resolution they helped to craft show that the
political construction of borderline relies exclusively on a naturalistic model of the
disordered personality. As we saw in Chapter 2, such a definition is biologically based
and relies on the belief that personality disorders have been and can be defined in terms
of biological dysfunction—this is to say, they are defined in terms of a deviation of
species typical biological function. In the case of borderline, it has been argued that this
dysfunction is ostensibly at the level of brain morphology and activity. However, we also
know that the official schedules of mental illness—the DSM and the 1CD—define
personality disorders according to deviations fiom social expectations. Thus the political
pronouncements about the status of borderline disorder seem to ignore the current
diagnostic consensus that such complex constellations of problematic behaviors are

irreducible to discrete biological dysfunctions. The resolution also contains language that

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is scientifically dubious and as yet unproven (e. g. “Whereas BPD is inheritable. . . ”).
Moreover, as a result of the eXplicit political endorsement of the biological model for
borderline, a dichotomy is set up and strengthened. Patients, clinicians, and family
members are left with the false choice, which I have tried to discharge, that borderline
patients are either grossly incapacitated or they are blameworthy.

The pervasive use of biological language is also ethically questionable because
such language provides tacit endorsement for the disease model espoused by
pharmaceutical companies, NAMI and other very powerfirl stakeholders in the mental
health policy arena. Such an endorsement does not necessarily entail that the suggested
disease model is unjustifiable. But recall, from the ethical considerations outlined in
chapter 5, that for a more ethically justifiable pragmatic ascription of mental disorder we
must critically examine the role of powerful stakeholders who motivate and grant these
ascriptions. Resonating the aforementioned insights of Herbert F ingarette, Peter Conrad,
and other scholars of medicalization, public misunderstandings about the methods and
processes of scientific advance are easily exploited by the scientific—industrial enterprise,
which pushes for technological solutions for complex social problems.

Such influence, of course, should not be surprising given that both National
Education Alliance for Borderline Personality Disorder and NAMI have historically
exerted serious political influence on lawmakers. In the case of NAMI, a House
resolution on borderline was a relatively minor political feat, considering political clout
they have enjoyed since the mid 1990’s when they were directed Laurie Flynn, whom
President Clinton appointed to the National Bioethics Advisory Commission. As I

mentioned previously, advocacy groups like NAMI have been under scrutiny for over a

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decade for their industry ties. Thus, the current political status of borderline disorder may
be a reflection of the particular goals of powerful moral entrepreneurship and disease
mongering machines mentioned in chapter 5.

This is not to deny the potentially positive impact such a legislative statement
might eventually produce. Indeed, attention by the National Institute of Mental Health
(N IMH) into personality disorders has increased and legislative recognition of the
importance of such research can only help to improve the chances of additional increases
in research funding. NIMH funds were initially allocated to complement the significant
work of Borderline Personality Disorder Research Foundation (BPDRF), which in 1999
began a programmatic effort to more fully examine the disorder and train researchers.
Ultimately, the NIMH hopes to establish a more robust psychiatric nosology based on its
Research Domain Criteria (RDoC) project, which “will build a framework for studying
mental illness across basic dimensions of mental functioning — such as emotion and

cognition. Cutting across traditional diagnostic categories, it will encompass multiple

levels of analysis, from genes to neural circuits to behaviors.”4

As both the lay public and politicians’ recognition of the borderline continues to
expand, demand for research and eventually a ‘cure’ will exert increasing pressure on
policymakers to appropriate more funds toward those ends. From an ethical-pragmatic
perspective, it will remain critically important to carefully examine the goals of this
research enterprise, calling attention to underlying philosophical and political
assumptions, as well as the arguably false promises such research may offer. One way to
do this is through the processes of deliberative democracy. Without presenting an

extensive description of those processes, we should note that the ideals of procedural

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ethics exemplified by deliberative democracy are grounded on a patently pragmatic
epistemologywthough the varieties of such an epistemology are broad and varied. For
purposes of addressing the ascription, treatment, and research into cases of mental
disorder, we can again turn to feminist philosophy for guidance on such a process. For
example, Susan Sherwin describes the need for deliberative democratic mechanisms to
provide guidance on research priorities and trajectories:
Research is a social and political activity, which has repercussions in our
collective lives. Unless explicit attention is paid to the need for more
democratic representation among the decision-makers responsible for
research programs, the science that is carried out will continue to be, by
and large, a science that supports the interests of the dominant groups in
society. Scientists should recognize their complicity in perpetuating
existing power structure and seek to increase their connection with, rather
than distance from the subjects of their work. They should see themselves
as accountable to the population at large, not merely the institutions and
corporations that support their work.5
Sherwin, who is of course not alone in proposing this imperative for ‘communicative
equality’, argues the demographics of research subjects should reflect the needs and
concerns of those who most need the help.6 She argues that the institutions of medical
funding and research—such as NIMH—are currently and inadequately representative. It
is therefore essential that policies establish mechanisms of participation by individuals
who suffer from borderline disorder either as patients or family members.7 An

overreliance on monolithic advocacy groups, which are fimded and, in some cases,

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managed by biomedical research firms will only stifle a more ethically justifiable
understanding of the irreducibly complex nature of borderline disorder, the influence of
power and social structures on its etiology, and efficacious treatments.

As Sherwin suggests, direct and respectful lines of communication to community
based advocacy groups—ideally groups that are less dependent on industry funding——
would go far to engender both trust and robust discussion among researchers, policy
makers, patient populations, and advocates. However, simply pointing to industry ties as
grounds to disparage and ignore the important work done by groups like NAMI would. be
imprudent. Rather, critical examination of the role of those ties on organizational
governance and decision—making should be intensified and made more transparent.
Moreover, in the case of mental illnesses such as borderline, it seems that a key task will
be to encourage the growth of a stronger grassroots network of patients and families,
perhaps communicating via blogs and social networking platforms, all aimed at providing
an alternative narrative to the political-industrial pronouncements that arguably
oversimplify their experience of suffering. It will be interesting to see how these
emerging forms of communication and political organizing will shape and reshape the
concept of mental disorder. In fact, the DSM-V website includes an open forum for
public comments and feedback. It remains to be seen how useful public feedback on
manual changes will prove to be. How should public concerns about the re-
categorization or the deletion of disorders be considered? Will public outcry be taken as
seriously as evidence-based proposals about the reliability and validity that support

reclassification?

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Future research and scholarship will be needed to hone deliberative democratic
processes for particular cases in which stakeholders might not have the ideal or ‘rational’
voice required to participate in the procedures established to collect public comment.
Indeed, critics of classical democratic deliberation, such as Iris Young, have argued that
only the privileged have a voice in the deliberative processes. The reclassification of
mental disorders like borderline—where patient/stakeholders are often marginalized as
irrational by virtue of their disorder—may offer a case study on the limits of standard
modes of democratic deliberation.

A current analogous case to monitor involves another boundary case of mental
disorder: Asperger’s syndrome. A heated debate has ensued about the APA proposal to
situate Asperger’s squarely within the category of autism spectrum disorders. The key
characteristics of Asperger’s are socially determined. They include an inability to pick up
on social cues, an aversion to changes in routine, and a preoccupation with very specific
subject matters. Many adults with Asperger’s, though they struggle with social
interactions, are gainfiilly employed and lead relatively happy lives. Thus, some
Aspergians and their advocates argue that subsuming the disorder within the autism
spectrum will stigmatize a set of unique capabilities—things like extraordinary
mathematical skills———that are actually a source of pride.8 DSM researchers, in general,
argue that the current diagnosis of Asberger’s does not reflect evidence that it is a high-
functioning variation of autism. Therefore, they argue, as a stand-alone diagnosis,
Asperger’s is often misunderstood both by clinicians and patients. The ongoing debate

about Asperger’s might provide insight into the ways reclassification of mental disorders

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will occur, as it will test the limits and coherence of movements aimed to democratize the

classification.

Reasonable Accommodation: ‘Mad’ versus ‘Bad ' Redux

Another significant policy implication resulting from the broadening diagnostic
and political recognition of boundary cases like borderline is directly related to the scope
of the Americans with Disabilities Act (ADA) and Family and Medical Leave Act
(F MLA). As borderline disorder is more widely diagnosed and considered to be a
biologically based brain disease, there will be increasing calls for reasonable
accommodations for patients in a variety of public settings from places of employment to
schools. Surprisingly, there has been very little written on this possibility and experts
with whom I have communicated have yet to encounter cases involving patients who are
seeking ADA accommodations or making social security claims based on their diagnosis
of borderline personality. It is my sense this relatively quiet state of affairs is the calm
before the storm.

Even a cursory search of blogs on borderline disorder will turn up discussion
threads such as the following, in which patients describe their limitations in maintaining
healthy interpersonal relationships and argue for employer accommodations:

makeshiftl4: I have been diagnosed as having Borderline Personality

Disorder, Generalized Anxiety Disorder, and Dysthemic Disorder. These

three combined are believed to have caused my memory loss. My IQ is

extremely high according to my psychotherapist who did a three day

intensive test session with me. My psychotherapist feels that I would

benefit from letting my work know I have Borderline Personality Disorder

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because I need less distractions, written and verbal instructions, and
positive criticism. Negative criticism may cause me to act on impulse. I
know Florida is an at will work state and the ADA does have protections
outlined for mental disabilities. Although the best treatment is time and
therapy, it is currently affecting my performance. I have a hard time
making friends or maybe even appear quiet to a lot of people. I have
always had a difficult time associating with people...If I come forward
and tell work why I am having such a hard time in the position now, will
they fire me for performance or will they move me to another vacant
position that has less public interaction? I work in a very large call center
and we have so many different positions there. . .I am extremely smart with
computers/electronics/typing/writing. My disability affects me in social
interaction. I have close similarities to someone that has Asperger's
disease.

inanightrnare: I can give you some information based [on] experience. I
went through much the same as you. My new boss had put me in a noisy
area and he was highly critical of me, even though I had been an
exceptional performer for nearly 9 years (always in a quiet environment,
though). I explained my issues to my new manager and the next thing I
know, he steps up the pace, being even MORE critical, putting me in an
even noisier environment and doing other things that were right out of the
mental disabilities “do not do” handbook. My performance continued to

decline. I attempted to get additional accommodations to help this

235

manager understand my limitations, but to no avail. I was terminated
within 6 months. I got a lawyer for awhile (until I was broke) and have
spent a year trying to fight for my rights, but it has been a lost cause. My

suggestion is to step cautiously. I dotted my i's and crossed my t's with

every step, but I still got fired.9
This thread reflects what I believe will be a larger trend in cases of borderline personality
disorder. As public recognition broadens, stigma may decrease, allowing patients with
borderline to ‘come out’ and insist that the problems they have been encountering in their
lives are the result of a ‘disease’. From the perspective of our pragmatic theory these
demands seem to be both predictable and reasonable. If borderline should be considered
an instance of mental disorder as any other, then it seems it should be covered under
policies such as the ADA. But what guidance would our pragmatic theory offer to such
difficult cases?

According to the pragmatic theory, demands such as the one described in the
above thread should not be met with a categorical and uncritical affirmation. Recall, the
theory aims to minimize the suffering of both the patient and those with whom she may
affect. Thus, both employers and borderline employees have respective duties to
prOperly manage the contentious situation. Employers would be responsible for
negotiating an ethically justifiable solution that takes into account all who are affected,
measuring the costs and benefits of reasonable accommodation versus reassignment or
termination. In a workplace where individuals generally complete tasks independently, a
worker who has borderline personality disorder might be perfectly suitable and highly

competent to successfully meet her responsibilities. Though there could be instances of

236

interpersonal difficulties, if managed correctly by both the employer and employee, these
could be diffused to avoid significant organizational strife.

In contrast, environments where functional teamwork is critical to success after a
period of reasonable accommodation, employee reassignment or termination might be
preferable if the dysfunctional behaviors prove to be refractory. One might argue that
interpersonal skills are just that—~——skills——and as such employers can justifiably demand a
certain level of competence. Of course such a demand must be made carefully and the
onus should be on the employer to prove they have attempted in good faith to reasonably
accommodate their employers psychological needs. (It should be noted that because of
employer-based health care, termination could have a profoundly adverse effect on the
long-term health of the individual.) In fact, we might adapt several of the virtues (i.e.
authentic beneficence, trustworthiness, empathy, uptake) described in chapters 5 and 6, as
well as Potter’s full set of communicative virtues, that were proposed to guide clinicians
in their diagnosis and treatment of borderline. Although we must recognize that the
context, relationships, and power structures that circumscribe the problematic borderline
behaviors are dramatically different, cultivation of these virtues might provide the needed
skills and strategies to employers who genuinely intend to accommodate employees
diagnosed with borderline personality disorder.

I should quickly mention one obvious difference between the patient-clinician
relationship and the employee-employer relationship. While patients have a particular
responsibility to participate in therapy and to try to get better, the borderline employee, it
would seem, has a different—perhaps greater—responsibility to help remediate the

dysfunctional situation since they are making a claim on others for accommodation. As

237

therapies such as dialectical behavior therapy become increasingly effective and widely
available, the employee should avail herself of such therapies, making a good faith effort
to learn the skills she needs to function more competently in her particular work
environment. Of course, the degree of responsibility or accommodation should be
subjected to further analysis and debate. The question of how the pragmatic theory might
help to address issues related to reasonable accommodations for persons with mental

disorders is complex and will therefore be a topic of fiiture research.

Expanding Access

Throughout chapters 5 through 7, I argued that the pragmatic theory of mental
disorder entails a particular set of ethical criteria be met across the continuum of
classification, diagnosis, and treatment of boundary cases of mental disorder. These
ethical criteria were set out to provide mental health professionals a general roadmap for
implementation of the pragmatic theory. In presenting these ethical considerations it was
assumed that mental health services were available and would be modified to the extent
suggested by the ethical subtheories. However, we should note that such an assumption
is problematic given the state of health care. While mental health parity policies have
made significant progress in expanding health services to the mentally ill, they remain
woefully insufficient to meet the needs of this growing population. In fact, research
suggests that both insured and uninsured patients encounter significant barriers to mental
health care services. Thus, to provide a more coherent pragmatic theory of mental
disorder we should look at ways to enhance access to the kinds of treatments that

ascriptions of mental disorder necessarily require.

238

As previously described, community and family outreach programs such
Assertive Community Therapies (ACT) and Dialectical Behavior Therapy-Family Skills
Training (DBT-F ST) courses offer promising ways to mitigate the effects mental
disorders like borderline through interfamily support groups and psychoeducation of
patients and family. It is difficult to ascertain precisely the availability of these services,
though NAMI programs and services are widely available. In contrast, more intensive in-
patient treatment programs are extremely expensive, are often only payable out-of-
pocket, and are resource and time intensive for families, patients, and providers. One

example is Gunderson Residence recently opened for treatment of adult women with

borderline personality disorder.10 Affiliated with McLean Hospital’s Center for the
Treatment of Borderline Personality Disorder, the Residence provides intensive therapy
over the course of several weeks, with a minimum stay of 60 days. The treatment
components include a variety of group and individual therapies and vocational and
educational counseling. At present, the $850 per day cost and limited space is prohibitive
for most patients. However, as a clinical pilot program, Gunderson Residence may
someday provide more effective treatments, in more locations, at a lower price.

A similar proposal has been made to specifically repurpose the Patient Centered
Medical Home (PCMH) model for mental health services. The PCMH model proposes
that primary care providers act as the hub coordinating a holistic medical care team. The
basic idea is to provide patients with streamlined access to needed specialists in a manner
that is enhances communication across all members of the care team, thereby improving
outcomes and hopefully also reducing costs. Because of the promised benefits of better

outcomes with reduced costs and enhanced payments for providers, the PCMH model has

239

been well received by clinicians, patients and policy makers alike. In the case of severe
and persistent mental illness however, the PCMH model faces some obstacles.
For example, Alakeson, et al. argue that most primary care providers lack the

experience to properly manage, treat, and coordinate the care of patients with severe

mental illnesses.“ As a result, mentally ill patients might not receive the care they need.
And even in a well functioning PCMH setting primary care providers may or may not
have ready access to services such as assertive community therapy programs. As a result,
relying on a medical home based in primary care for mentally ill patients may not be the
best way forward. Instead, Alakeson, et al. propose the development of a specific form of
medical home designed for mentally ill patients. These specialty care medical homes
would rely on partnerships with primary care providers but would be mental health care
providers would serve as the coordinating hub patient care. The key rationale for

developing such a model is that it would provide mental health care in an “understanding

and experienced environment.”12

Critics might object that this model bolsters the stigma of mental illness by
sequestering sick people in specialty homes where their array of medical problems are
made secondary to their psychological illness. Alakeson, et a1. reply that, “the goal in
[creating a specialty medical home for mental illness] is not to reinforce the segregation

of people with severe and persistent mental disorders, as some fear, but to identify the

most expedient way to address their urgent health care needs.”13 I am sympathetic to this
line of reasoning and to their proposal in general. A specialty medical home model for

mental illness would in theory offer patients access to a team of highly competent mental

240

health practitioners first instead of second, and as a result, these specialists will be adept

at managing the complex needs of this population.

Future Research

In conclusion, there is much work to be done at the intersection of philosophy of
medicine, psychiatry, psychology, and public policy. This dissertation was an attempt to
craft a pragmatic approach to more adequately understand instances of mental disorder
that currently fall through the theoretical lacuna of standard nosological theories. My
motivation for developing a set of pragmatic and ethical justifications to more clearly
identify and treat mental disorders has been to establish a more solid foundation for better
public policy. My hope was to set aside arguments concerning the metaphysical status of
boundary cases that often give rise to questions about their legitimacy. Instead I argued
that such questions distract us from the central problem: the behaviors in question cause
suffering—a form of suffering that is potentially remediable by medical or psychological
treatment. By shifting my study away from foundational claims about the actual status of
mental disorders like borderline, I hope I have redirected philosophical attention to the
problem of the behaviors as such. I have no illusions that my theory is without rough
edges. Indeed, key issues that I intend to continue to investigate in my future research
include the following conceptual questions:

Do the ethical subtheories and considerations I have proposed, and those in the

literature I have reviewed, ensure (to the greatest extent possible) that pragmatic

ascriptions of mental disorder are made in ethically justifiable manner?

241

From a public health perspective, what is the scope of suffering—either in terms
of individual persons or in terms of intensity of suffering—that is acceptable or

unacceptable before considering a disorder a candidate for a pragmatic ascription
of disorder?

How might a pragmatic ascription of disorder affect the way we think about

freedom and responsibility and what will the ramifications be for criminal justice?

Related to these conceptual questions are empirical ones that, if answered, would help

implement the theory and provide evidence of its strengths and weaknesses. For example:
Can a pragmatic ascription of mental disorder, properly understood by clinicians

and caregivers, improve therapeutic outcomes and reduce stigma?

Is a pragmatically motivated diagnosis, itself, therapeutic?

What kinds of educational interventions for clinicians might be needed to

implement the theory? How will these interventions be assessed?

How might new scientific data on brain function, such as fMRI studies, affect our
understanding of social dysfunction?
Such questions represent just a handful of many that will or could emerge when thinking

about boundary cases of mental disorder in the way I have proposed. This dissertation is

therefore a promissory note to pursue these additional lines of investigation.

 

I. H. Res. 1005: Supporting the goals and ideals of Borderline Personality Disorder Awareness
Month. April 1, 2008. (accessed June 2, 2010'. littpzflwwwugovtrack.us/congicssxbill.xpd'?bill=hrl10-1005)
The text of the resolution is as follows: Whereas borderline personality disorder (BPD) affects the
regulation of emotion and afflicts approximately 2 percent of the general population; Whereas BPD is a
leading cause of suicide, as an estimated 10 percent of individuals with this disorder take their own lives;

Whereas BPD usually manifests itself in adolescence and early adulthood; Whereas symptoms of BPD
include self -injury; rage; substance abuse; destructive impulsiveness; a pattern of unstable emotions, self-
image, and relationships; and may result in suicide; Whereas BPD is inheritable and is exacerbated by
environmental factors; Whereas official recognition of BPD is relatively new, and diagnosing it is often
impeded by lack of awareness and frequent co-occurrence with other conditions, such as depression,

242

 

bipolar disorder, substance abuse, anxiety, and eating disorders; Whereas despite its prevalence, enormous
public health costs, and the devastating toll it takes on individuals, families, and communities, BPD only
recently has begun to command the attention it requires; Whereas it is essential to increase awareness of
BPD among people suffering from this disorder, their families, mental health professionals, and the general
public by promoting education, research, funding, early detection, and effective treatments; and Whereas
the National Education Alliance for Borderline Personality Disorder and the National Alliance on Mental
illness have requested that Congress designate May as Borderline Personality Disorder Awareness Month
as a means of educating our Nation about this disorder, the needs of those suffering from it, and its
consequences: Now, therefore, be it Resolved, That the House of Representatives supports the goals and
ideals of Borderline Personality Disorder Awareness Month.

2. Tom Davis, Ranking member, Committee on Oversight and Government Reform. “History of
Borderline Personality Disorder Awareness Month,” National Education Alliance for Borderline
Personality Disorder, Accessed May 15, 2010
http://www.borderlinepersonalitydisorder.com/awareness/awareness-f1lesfbackgroundshtml

3. Chris Van Hollen, Statement of Congressman Chris Van Hollen on H. Res. 1005 Committee on
Oversight and Government Reform. Accessed May 15, 2010

http://www.borderlinepersonalitydisorder.com/awareness/awareness-f1les/background.shtml

4. Thomas lnsel, “Re—Thinking Classification of Mental Disorders,” Director’s Blog. February 0],
2010 http://www.nimh.nih.gov/about/director/ZOl0/re-thinking-classifrcation«of-mental-disorders.shtml
(accessed June 23, 2010)

5. Susan Sherwin, No Longer Patient: Feminist Ethics and Health Care (Philadelphia, PA:
Temple University Press, 1992), I73.

6. Janet Farrell Smith, “Communicative Ethics in Medicine: The Physician-Patient Relationship,”
in Feminism and Bioethics: Beyond Reproduction, ed. by Susan M. Wolf (New York: The Hastings Center,
1996),184-215.

7. 1 should note that NIH/NCRR Clinical and Translational Science Awards are structured to

include community outreach and participation in research program development and implementation. See:
NCRR Fact Sheet, “Clinical and Translational Science Awards” Accessed July 2010,

www.mcrrnihgov/ctsa
8. Greg Miller, “Anything But Child's Play,” Science 5 327 (March 2010): 1192-1 193.

9. Expert Law Discussion Forum: Medical and Disability Issues Laws and regulations concerning
disabilities in the workplace, including the ADA and FMLA.

http://www.expertlaw.com/forums/showthread.php?t:676l8 (accessed June 1, 2010)
10. Gunderson Residence. http://www.gundersonresidenceorgl (accessed June 30, 2010)

ll. Vidhya Alakeson, Richard G. Frank and Ruth B. Katz, “Specialin Care Medical Homes for

People with Severe, Persistent Mental Disorders,” Health Affairs 29 no. 5 (2010): 867-873.
12. lbid, 870.

13. lbid, 870.

243

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