Philosophy, Psychiatry, & Psychology

Interdisciplinary work of the sort attempted in my paper is fraught with risks and obstacles. One especially pernicious obstacle is the short-sighted prejudice that insists we should always divide a problem into its various components, allocate different parts to their respective disciplines, publish each separately, and, above all, keep the ethics separate from the rest. Although this may sometimes constitute good tactical advice in the mature stages of inquiry on a complex topic, it begs the question in the early initial stages of discussion on a subject like the present one, which is tangled and complex and not suited to the traditional disciplinary boundaries of professional journals.

I am grateful that both my commentators have generously overlooked the many weaknesses in my paper and focused instead on the most pressing issue of substance. This is the thesis that the issues described are important to psychiatry and deserve to be discussed more thoroughly. I therefore feel vindicated in assuming the risks I did, despite knowing there is so much more to be done; notably, moving from anecdotal data to more reliable forms of evidence. The entire episode speaks pointedly to the need for journals like Philosophy, Psychiatry, & Psychology and its innovative mandate.

Before I address the remarks of my commentators, some background information on the circumstances that led to the writing of the paper might help readers to understand its wide interdisciplinary scope, its admittedly speculative character, its sense of urgency, and what some may consider its rhetorical excesses. The paper arose as the result of anecdotal data gathered during the course of several years of clinical ethics work and student supervision in various hospital and academic institutions. It was the personal experience of hearing the struggles of a young student with a history of "weborexia" that finally prompted me to write the paper. She and others who shared their experiences with me spoke of how friends were "triggered" and often relapsed as a result of accidental visits to "pro-ana" and "cutting" sites and chat rooms. My worst fears were confirmed when I started visiting these sites myself. All the dangers I found have invariably been reaffirmed by clinicians at public lectures where I have spoken on this topic. Many clinicians tell stories of patients being lured back to unhealthy social associations and illness behaviors as a result of Internet activity.

As I extended my informal forays on the Internet to web sites for other controversial mental health conditions, it soon became evident that I was embroiled in a new historical and clinical psychiatric phenomenon of great complexity, one that raised novel ethical questions about self-determination and autonomy, and reached back to the old debate about psychiatric labels of the 1970s, raised by Goffman, Scheff, Szasz, and others. Incidentally, this originally is where my use of the word label is taken from. The problem [End Page 361] is that since the time it originated in the sociology of medicine, the evolving and multiple disciplinary uses of the term label make it virtually impossible to define it in a manner that will satisfy everyone. Fortunately, both of my commentators seem to recognize this fact. Accordingly, they do not waste time criticizing my admittedly loose and flexible use of the term, as I employ it to point to issues of greater substance—where hopefully it can eventually be more clearly defined in the course of inquiry. This theoretical openness and generosity is evident throughout these two very interesting commentaries, both by seasoned clinicians.

In outline, there are three levels of inquiry involved in my paper. My two commentators make valuable points and observations on all three levels, which I now propose to address in that order.

First, in the widest sense, my paper is intended as a contribution to the history of psychiatry. It is an historical and sociological reflection on new developments in the dynamics that govern the way diagnostic categories are used in psychiatric labeling, including relevant ethical considerations, such as, for example, whether the application or removal of a label is considered ethically good or bad, as well as when, and why, and by whom. In...