Responsibility without Blame: Philosophical Reflections on Clinical Practice

My first experience as a clinician was in a Therapeutic Community for service users with personality disorder. As well as having personality disorder, many of the Community members also suffered from related conditions, such as addiction and eating disorders. Broadly speaking, these conditions are what we might call ‘disorders of agency’. Core diagnostic symptoms or maintaining factors of disorders of agency are actions and omissions: patterns of behaviour central to the nature or maintenance of the condition. For instance, borderline personality disorder is diagnosed in part via deliberate self-harm and attempted suicide, reckless and impulsive behaviour, substance use, violence, and outbursts of anger; addiction is diagnosed via maladaptive patterns of drug consumption; eating disorders involve eating too much or too little. If a service user is to improve let alone recover from these disorders, they must change the diagnostic or maintaining pattern of behaviour (cf. Pearce and Pickard, 2010). For instance, service users with borderline personality disorder must stop self-harming; addicts need to quit using drugs or alcohol; anorexics must eat
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