Wednesday, May 20, 2009

Moral Treatment and the Personality Disorders

A few comments on one article of particular interest to me, "Moral Treatment and the
Personality Disorders" by Louis Charland in The Philosophy of Psychiatry: A Companion, Jennifer Radden [3d], [Oxford Universit Press, 2004] [pp64-77].
I became interested in Charland because of what he has written about Philippe Pinel, whose work I have been researching for a few years. His thoughts about Personality Disorders are of more general interest. His argument is that Cluster B personality disorders [Anti-social, and Borderline] are not medical kinds but what he calls interactive kinds and should not be within the purview of medicine. His argument is that the treatment of Axis I disorders as well as Cluster A and Cluster C disorders do not require "the sort of moral willingness and effort required by
Cluster B disorders." While "the dependent individual," he notes, "may annoy others … [he/she] does not necessarily intend to annoy them for the sake of it." Charland suggests that people with Cluster B disorders do intend the annoying [harmful] effects they have on others and therefore require a moral treatment, not a medical one, that will help them to intend otherwise. I find his distinction between moral and medical treatments unsatisfactory, to say the least. My own experience with people with Antisocial and Borderline diagnoses is that they like people with any disease, pursue treatment [if we must use that term] to diminish their own personal suffering and not to be be better people [more thoughtful of others feelings]]. The threat of jail is modestly good "treatment" for some people with an Antisocial diagnosis and when Borderlines benefit from treatments [like DBT], it is because help them feel better. It seems to me that the whole
discussion of "kinds" is as misguided when it is pursued by critics of psychiatry like Charland, as it is when it is done by the authors of the DSM.
Charland reveals himself to be a dualist, identifying a realm of
actions that one intends and one that one does not intend. While this
is not the cartesian dualism of substances, it serves the same
function--to distinguish that which we are responsible for--mind,
intention, from that which we are not responsible for--body, cluster A
syndromes. Psychotherapy as inspired by Freud [and Pinel, I would
argue] in contrast is based on a monist principle. Psychoanalytic
discourse does not make a distinction between the intended and the not
intended, or perhaps I should say that the concept of unconscious
motivation is a a concept that joins the intentional and unintentional
in a way that allows one to talk about the intentional in a non
judgmental way. It makes moral therapy as Charland uses it obsolete. I
think that Charland is thinking in pre-Freudian terms and from reading
his work on Pinel, he is also thinking in eighteenth-century dualist
[though obviously not about substances] terms as well.

1 comment:

  1. walter vandereycken7/23/2009 2:56 PM

    Charland has written many interesting articles on core issues in psychiatry; if you want to correspond with him: