personality disorder, ethics, responsibility
We are thankful for the opportunity to reflect more on the difficult problem of the relationship between moral evaluations and the construct of personality disorders in response to the commentaries by Mike Martin and Louis Charland. We begin by emphasizing to readers that this important problem is complicated by the different perspectives of the various disciplines involved, especially, philosophy, psychiatry, and psychology. Incredulity, anger, and dismay are among the reactions we encountered in discussions of these issues, especially with some mental health professionals. Strong reactions on either side of a disciplinary divide occasionally present barriers to a dispassionate discussion of the topic.
Regarding our use of the term psychiatric disorder in the target article, we do not read ourselves as having asserted that Charland believes that psychiatric disorders in general are moral not clinical kinds. The question is whether or not borderline and narcissistic personality styles are psychiatric disorders or whether they are only morally disvalued conditions. We then borrowed Charland’s idiom—are these personality styles called borderline and narcissistic moral kinds or are they legitimate psychiatric disorders (clinical kinds). That was how we meant the term “psychiatric disorder” when we used it.
Seeing ourselves as playing an intermediary role, our article attempted to articulate to mental health professionals what is so compelling about the critiques of thinkers such as Charland. This goal partly accounts for Charland’s accurate observation of an imprecision in our language. Early in the article we defined his position as being specific to cluster B personality disorders and our own target examples of personality disorders were drawn from cluster B. From our perspective, however, the problem is not limited to the cluster B disorders. Our thinking on this matter was initiated by Charland’s (2006) claim that a dimensional analysis of cluster B disorders might justify their clinical status. In contrast, we suggest not only that a dimensional model will fail to eliminate the problem; it may even make the problem worse.
The various kinds of personality disorders that could be identified using a dimensional model approach would swamp the current list of ten categories. Many different kinds of personality constellations could be diagnosed as disordered because of very high levels of neuroticism and low levels of agreeableness, and then differentiated [End Page 131] from each other on the basis of additional traits. Agreeableness is a trait with moral connotations, including honesty, altruism, and compassion. The implications of this analysis are striking: if someone is consistently likeable and friendly, they are less likely to be diagnosed as personality disordered. This also true for cluster A and cluster C disorders, although cluster B is clearly the more problematic group. With this point in mind, we did refer to personality disorders in general.
Just as important, we offered skeptics a more compatibilist perspective on the problem of whether we are dealing with a character disorder or a moral failing. By compatibilism we mean the view that the constructs for cluster B personality disorders can be considered both morally and clinically. For example, let us consider two criteria for personality disorder—namely, impulsivity and lack of empathy. Charland writes that because the cluster B personality disorders are largely identified using such moral criteria, then they are primarily moral rather than clinical kinds. Our compatibilism states that, in the appropriate context, a trait such as impulsivity is both moral and clinical and should not be considered to be primarily moral rather than clinical.
Our view is that an individual clinical diagnostic criterion such as impulsivity should be understood as an indicator of a disorder within a theoretical context, ideally with some theory of the underlying pathological process specified. In this view, traits such as impulsivity and manipulativeness are not invariably disordered, but they can become so by being expressions of a dysfunctional personality structure. That is, individual symptoms should not be considered independently of one another but as part of a cluster of problems.
Furthermore, traits do not become nonclinical simply because they also play a role in a moral framework/theory as well. Charland seems to agree...