Answering the Neo-Szaszian Critique: Are Cluster B Personality Disorders Really So Different?
Buy Issue for $25 at JHUP- Answering the Neo-Szaszian Critique: Are Cluster B Personality Disorders Really So Different?
DSM, models of disease, moral therapy, personality disorder, psychopathology
I was delighted to be asked to comment on Peter Zachar’s paper, partly because he presents an elegant proposal for how personality disorders (PD) might be considered to fit into a broadly medical conception of disorder, but also because the overlap between moral and clinical elements of disorder, and more broadly moral and clinical psychiatric kinds, seems to me to be a question central to the theory and practice of psychiatry. The moral context of diagnosis and treatment is a question not just in the PD field (Pearce and Pickard 2009, 2010). The fact that over half of prisoners in the United Kingdom have a PD and a similar number can be diagnosed with a neurotic disorder (Singleton, Meltzer, and Gatward 1998) should itself challenge the way we tend to consider the categories of moral and clinical separately.
Louis Charland’s challenge, to which Zachar responds, is simple: the Cluster B PDs are defined to a great extent by criteria with clear moral content; if the moral content were stripped out, the remaining description would be insufficient to define a disorder and therefore they are properly thought of as moral, as opposed to clinical, kinds. Charland is careful not to question the scientific (or empirical) basis of the Cluster B PDs (although he does entertain the normal doubts about this [Charland 2006]); nor does he contend that for something to be a moral kind, it cannot also be a clinical kind (Charland 2010). Zachar accepts the challenge, and proposes a number of conceptual models for the Cluster B PDs which might establish their clinical nature.
I start by briefly considering Charland’s argument. I then consider whether Zachar’s proposals answer it. I conclude by considering Charland’s dismissal of the ‘argument from treatment’ and the discord between his argument and the realities of clinical practice.
The Definition of ‘Clinical Kind’
Charland suggests that for a problem to constitute a clinical (or medical) kind, two conditions must be met. First, it should be recognizable through primarily clinical (meaning nonmoral) [End Page 203] features. Second, it should be established that it is properly treated by health professionals (“subject to and amenable to clinical treatment and therapy,” [Charland 2006, 120]) rather than merely causing clinical distress—this is the ‘argument from treatment.’ He claims that neither condition is met for the Cluster B PDs. The first condition is not met either in the ‘thin’ definitions of the DSM-IV (American Psychiatric Association 1994) or the ‘thick’ descriptions of the DSM-IV Casebook (American Psychiatric Association 1995). And the second condition is not met because mental health professionals are not trained to treat moral problems, and, in the case of the Cluster B PDs, medical or psychiatric treatment is not effective. He holds this is straightforward with respect to the effectiveness of psychiatric drugs; in the case of psychotherapy, he contends that the effectiveness of psychological treatment is related to the extent to which it contains moral elements, using the example of dialectical behavior therapy (Charland 2006).
This argument can be straightforwardly refuted if it proves to be the case that clinicians are in fact trained to address the moral aspects of psychiatric disorder, and indeed are successful in doing so. If appropriately prescribed psychiatric medication is effective, then the basis of Charland’s argument is undermined; if psychotherapy is an effective form of treatment, then, to counter Charland, either the nonmoral aspects of the therapy would need to be shown to be pivotal in recovery, or the essentially dual (moral and clinical) nature of the therapy would need to be established.
Zachar’s Response to Charland’s Thesis
Zachar does not challenge Charland’s argument. Rather he aims to meet it by exploring various models that would validate the clinical nature of Cluster B PDs.
The Vulnerability Model
Zachar suggests that PDs might be ‘clinically relevant,’ if not clinical kinds themselves, because they represent vulnerabilities to Axis I disorders, just as hypertension represents a vulnerability to cardiovascular disease. The problem with this suggestion is that...
