Articles: In the Spirit of Giving Uptake
By Nancy Nyquist Potter
Philosophy, Psychiatry, & Psychology - Volume 10, Number 1, March 2003, pp. 33-35
IT IS BOTH WONDERFUL and daunting to now be in the middle of a dialogical exchange on the messy and difficult topic of self-injury and how ethically to interact with patients who self-injure. It is wonderful that authors such as Carolyn Sargent have contributed very helpful examples from the discipline of anthropology that expand the ideas I have been grappling with. And it is daunting to begin to sharpen and correct my thoughts along the lines that the commentators suggest. In the spirit of giving uptake both to the praise and the criticism I have received, I first situate the "Commodity/Body/Sign" article in the context of my larger project and then focus on one problem area: my claim that giving uptake is necessary to ethical healing practices.
Giving Too Much Uptake to the Dsm
Rob Woolfolk is right that borderline is diagnostically imprecise. But what initially caught my interest in this personality disorder was its pejorative connotations. I will mention my favorite example, which comes from a past chairman of the psychiatry department at New York University that "borderliners are the patients you think of as PIAs—pains in the ass," (Medical World News 1983). Why are the patients who exhibit the behaviors associated with borderline personality disorder (BPD) so disliked, I wondered? Who are these patients, and what are they doing that brings upon themselves such rejection? My investigation, in other words, has been focused on behaviors and their meanings, using a philosophical lens to examine underlying assumptions. I completely agree with Woolfolk and Carolyn Sargent that much more analysis needs to be done on BPD, and I am eager to do it. It is true that I do not take up larger questions about the gendered nature of this diagnosis in general (Sargent, Woolfolk), nor do I challenge the validity of the diagnosis in this article (Woolfolk). In my view, that larger project must be held in abeyance until more philosophical probing on a number of other issues is done. Hopefully, my book-length project will benefit from continuing guidance from these authors.
I focus first on self-injury for two reasons. First, it is the most common symptom for which people with BPD come to clinical attention (Gunderson 2001, 22). Second, of all the behaviors associated with BPD, self-injurious behavior is the kind that people most tend to dig in their heels about when its status as pathological is questioned. Gunderson cautions that "because the diagnosis of BPD underscores a serious, long-standing mental health problem, the diagnosis should not be offered too readily to anyone who cuts or otherwise self-mutilates" (2001, 23). I add to that caution that we ought not too readily assume that self-injury is pathological: Lynne Cox (2003) swam to the Antarctic Peninsula in water temperatures of 32° Fahrenheit and with 25 foot waves; she suffered nerve damage and numbness in her extremities. Self-injurious behavior? [End Page 33] Pathological? Cox trained for two years to accomplish this feat. In problematizing self-injury, I raise questions about some associations and assumptions we make. Calling into question the whole taxonomy requires looking at symptoms, behaviors, and criteria as a whole, and that cannot be done until systematic analysis of concepts such as self-injury, impulsivity, identity disturbance, and manipulativity are undertaken. To put things in terms of Woolfolk's reasonable criticism that he wishes I would "give less uptake to the framers of the DSM-IV," I appreciate that point. But I do think that those of us who are not ourselves clinicians must do our research carefully and proceed conservatively rather than attempting to tear a house down that may not need to be condemned.
Methods and Morals
Woolfolk says that the concept of uptake is "familiar and central" to therapy; Katherine Morris says it is "simple and uncontroversial"; Sargent says it is "unexceptionable"; and Christa Krüger says it may be "very difficult if not more or less doomed to fail." I am amused at these responses. I agree that therapeutic work—and interpersonal interactions in general—must rely on good listening skills. My emphasis on uptake is about a kind of listening that asks the listener to suspend his or her usual interpretive frameworks to some degree. Although we cannot step outside all cognitive frameworks at once, we can and sometimes should be skeptics about our own ontological commitments. Giving uptake properly sometimes requires that we shift away from the prevailing lenses we use in understanding others; it may mean that we situate ourselves, epistemologically and emotionally speaking, on rather unstable ground.
Giving uptake, then, can be understood as a kind of methodology, because it involves taking a particular stance toward another's communications. One way to understand Krüger's criticism of my claim that giving uptake is an appropriate ethical practice for clinicians is that, although I have given reasons in favor of giving uptake, I have not discussed the reasons not to give uptake. Morris may be making a similar point when she asks whether the virtue could be Aristotelian, in which case it would admit of extremes in either direction. It is important to address the limits of giving uptake, and I am grateful to Krüger and Morris for raising this point, if that is what they meant. I do, in fact, think that giving uptake is an Aristotelian kind of virtue (see Potter 2000, 2002). It has an excess and a deficiency; in Aristotelian fashion, I emphasize the vice of deficiency because it is the more worrisome one. But it is true that we can give uptake when we should not. The difficulty for each of us is determining the scope and limits of this, or any other, virtue, because virtue ethics is not a systematized, rule-governed approach to morality. Instead, we must develop dispositional attitudes that are guided by practical reasoning.
But if Krüger's imaginary interpretation is meant, in part, to illustrate the point that giving uptake is sometimes wrong to do, I do not think her scenario works. Krüger does a lovely job of explicating the argument in my paper, but her criticism rests on a number of superimposed frameworks that preempt the possibility of a clinician giving uptake to the self-injuring patient. Let me explain.
I am troubled by Krüger's methodology. The use of Szasz's theories of mental illness is question-begging for the kind of situation I am addressing: Szasz assumes both that the person is communicating and that the person is feeling distress. I resist those assumption. Szasz (and Foucault [1988]) are sometimes trenchant in their critiques of societal responses to those who deviate from social norms. But I do not assume that framework regarding all mental illness; I do think there are some mental illnesses (schizophrenia, bipolar disorder, major depression) that are not mere matters of social construction and of the political policing of persons. Krüger's point, I take it, is that clinicians run the risk of scapegoating/sacrificing patients by treating them as deviants. But to make that argument, she imposes a particular explanatory theory onto the interactions. Whereas I offered various theories of explanation for BPD patients who self-injure, I am not confident that any of them fits most self-injurious patients or even that, taken together, [End Page 34] we have enough theories to choose from. I think Krüger is making a mistake in using those explanatory theories to draw out an imaginary double bind for clinicians.
Surely clinicians and the rest of us occasionally face double binds in our work and life. Double binds are neither unique to giving uptake nor inherent in giving uptake. I worry that Krüger is closing off the very thing my article is hoping for: the possibility that, by not imposing ready-made theories and interpretations on patients, we may discover new knowledge.
I also worry that Krüger inadvertently stereotypes the patient diagnosed with BPD in just the ways that led me to worry about clinicians' attitudes about BPD in the first place. She imagines that the clinician will be "forced [by the patient] to subscribe simultaneously (albeit subconsciously) to opposing points of view" (2003, 20) She imagines that the clinician is compelled by incomprehensible communications from the patient to "declare the patient insane." 1 Then she imagines that the clinician feels "blame that emanates from the patient" and that the "patient also punishes the clinician" (2003, 20). Krüger seems to assume that the patient is manipulative, wildly erratic in her motivations and needs, and not to be trusted. Krüger is most likely exaggerating the imaginary encounter to make her point, but it is an unfortunate direction to take the problem of giving uptake in excess or when not appropriate.
On the other hand, Krüger is right to point out difficulties in giving uptake properly. Giving uptake is seldom straightforward. I completely agree that we sometimes receive conflicting communications from others. Contradictory, confusing, or inchoate communications make giving uptake difficult. But when this kind of thing happens, we can point it out; we can ask for clarification; we can say why we have reservations about giving uptake to a particular communication. The process of giving uptake need not—in fact, usually should not—conclude in one exchange, or mostly continue as fantasy inside the clinician's mind. When done well, uptake involves a dynamic interplay of exchanges that works toward making more explicit and clearer what each person does and does not mean.
Perhaps it will be useful to remind readers that to say that the body is text is not to say that it is always a text, and to situate body modifications within a framework where the body is understood as a text is not to say that each and every thing we do with and to our bodies is meaningful and requires interpretation. Thus, although it may be the case that, as Sargent quotes Bordo, the body of a "disordered" woman is a text that insists on being read as a cultural statement, I would strongly resist making that an a priori assumption either in interacting with one particular woman or women in general. It may turn out that each and every act of self-injury is a sign requiring interpretation, but we do not know that yet. Even if we did, we ought not to decide in advance what a given self-injurious act means. Likewise, it may turn out that the best way to conceptualize delicate and severe self-injury is on a continuum (Sargent), but we do not know that yet, either. We need to listen more, and listen in a particular way, to BPD patients who self-injure before we can know how to interpret and evaluate and classify the various acts that we now count as self-injury.
--------------------------------------------------------------------------------
Endnote
1. This is a mistake; insanity is a legal, not medical term.
References
Cox, L. 2003. The New Yorker. February 3:66-74.
Foucault, M. 1988. Madness and civilization: A history of insanity in the Age of Reason. Trans. R. Howard. New York: Vintage Books.
Gunderson, J. 2001. Borderline personality disorder: A clinical guide. Washington, D.C.: American Psychiatric Publishing.
Krüger, C. 2003. Self-injury: Symbolic sacrifice/self-assertion renders clinicians helpless. Philosophy, Psychiatry, & Psychology 10:17-21.
Potter, N. 2000. Giving uptake. Social Theory and Practice 26:479-508.
Potter, N. Liberatory psychiatry and an ethics of the in-between. In Ethics of the body: Postconventional challenges. Ed. Shildrick, M., and R. Mykitiuk (forthcoming).
Potter, N. 2002. How can I be trusted? A virtue theory of trustworthiness. New York and Oxford: Rowman-Littlefield.
IT IS BOTH WONDERFUL and daunting to now be in the middle of a dialogical exchange on the messy and difficult topic of self-injury and how ethically to interact with patients who self-injure. It is wonderful that authors such as Carolyn Sargent have contributed very helpful examples from the discipline of anthropology that expand the ideas I have been grappling with. And it is daunting to begin to sharpen and correct my thoughts along the lines that the commentators suggest. In the spirit of giving uptake both to the praise and the criticism I have received, I first situate the "Commodity/Body/Sign" article in the context of my larger project and then focus on one problem area: my claim that giving uptake is necessary to ethical healing practices.
Giving Too Much Uptake to the Dsm
Rob Woolfolk is right that borderline is diagnostically imprecise. But what initially caught my interest in this personality disorder was its pejorative connotations. I will mention my favorite example, which comes from a past chairman of the psychiatry department at New York University that "borderliners are the patients you think of as PIAs—pains in the ass," (Medical World News 1983). Why are the patients who exhibit the behaviors associated with borderline personality disorder (BPD) so disliked, I wondered? Who are these patients, and what are they doing that brings upon themselves such rejection? My investigation, in other words, has been focused on behaviors and their meanings, using a philosophical lens to examine underlying assumptions. I completely agree with Woolfolk and Carolyn Sargent that much more analysis needs to be done on BPD, and I am eager to do it. It is true that I do not take up larger questions about the gendered nature of this diagnosis in general (Sargent, Woolfolk), nor do I challenge the validity of the diagnosis in this article (Woolfolk). In my view, that larger project must be held in abeyance until more philosophical probing on a number of other issues is done. Hopefully, my book-length project will benefit from continuing guidance from these authors.
I focus first on self-injury for two reasons. First, it is the most common symptom for which people with BPD come to clinical attention (Gunderson 2001, 22). Second, of all the behaviors associated with BPD, self-injurious behavior is the kind that people most tend to dig in their heels about when its status as pathological is questioned. Gunderson cautions that "because the diagnosis of BPD underscores a serious, long-standing mental health problem, the diagnosis should not be offered too readily to anyone who cuts or otherwise self-mutilates" (2001, 23). I add to that caution that we ought not too readily assume that self-injury is pathological: Lynne Cox (2003) swam to the Antarctic Peninsula in water temperatures of 32° Fahrenheit and with 25 foot waves; she suffered nerve damage and numbness in her extremities. Self-injurious behavior? [End Page 33] Pathological? Cox trained for two years to accomplish this feat. In problematizing self-injury, I raise questions about some associations and assumptions we make. Calling into question the whole taxonomy requires looking at symptoms, behaviors, and criteria as a whole, and that cannot be done until systematic analysis of concepts such as self-injury, impulsivity, identity disturbance, and manipulativity are undertaken. To put things in terms of Woolfolk's reasonable criticism that he wishes I would "give less uptake to the framers of the DSM-IV," I appreciate that point. But I do think that those of us who are not ourselves clinicians must do our research carefully and proceed conservatively rather than attempting to tear a house down that may not need to be condemned.
Methods and Morals
Woolfolk says that the concept of uptake is "familiar and central" to therapy; Katherine Morris says it is "simple and uncontroversial"; Sargent says it is "unexceptionable"; and Christa Krüger says it may be "very difficult if not more or less doomed to fail." I am amused at these responses. I agree that therapeutic work—and interpersonal interactions in general—must rely on good listening skills. My emphasis on uptake is about a kind of listening that asks the listener to suspend his or her usual interpretive frameworks to some degree. Although we cannot step outside all cognitive frameworks at once, we can and sometimes should be skeptics about our own ontological commitments. Giving uptake properly sometimes requires that we shift away from the prevailing lenses we use in understanding others; it may mean that we situate ourselves, epistemologically and emotionally speaking, on rather unstable ground.
Giving uptake, then, can be understood as a kind of methodology, because it involves taking a particular stance toward another's communications. One way to understand Krüger's criticism of my claim that giving uptake is an appropriate ethical practice for clinicians is that, although I have given reasons in favor of giving uptake, I have not discussed the reasons not to give uptake. Morris may be making a similar point when she asks whether the virtue could be Aristotelian, in which case it would admit of extremes in either direction. It is important to address the limits of giving uptake, and I am grateful to Krüger and Morris for raising this point, if that is what they meant. I do, in fact, think that giving uptake is an Aristotelian kind of virtue (see Potter 2000, 2002). It has an excess and a deficiency; in Aristotelian fashion, I emphasize the vice of deficiency because it is the more worrisome one. But it is true that we can give uptake when we should not. The difficulty for each of us is determining the scope and limits of this, or any other, virtue, because virtue ethics is not a systematized, rule-governed approach to morality. Instead, we must develop dispositional attitudes that are guided by practical reasoning.
But if Krüger's imaginary interpretation is meant, in part, to illustrate the point that giving uptake is sometimes wrong to do, I do not think her scenario works. Krüger does a lovely job of explicating the argument in my paper, but her criticism rests on a number of superimposed frameworks that preempt the possibility of a clinician giving uptake to the self-injuring patient. Let me explain.
I am troubled by Krüger's methodology. The use of Szasz's theories of mental illness is question-begging for the kind of situation I am addressing: Szasz assumes both that the person is communicating and that the person is feeling distress. I resist those assumption. Szasz (and Foucault [1988]) are sometimes trenchant in their critiques of societal responses to those who deviate from social norms. But I do not assume that framework regarding all mental illness; I do think there are some mental illnesses (schizophrenia, bipolar disorder, major depression) that are not mere matters of social construction and of the political policing of persons. Krüger's point, I take it, is that clinicians run the risk of scapegoating/sacrificing patients by treating them as deviants. But to make that argument, she imposes a particular explanatory theory onto the interactions. Whereas I offered various theories of explanation for BPD patients who self-injure, I am not confident that any of them fits most self-injurious patients or even that, taken together, [End Page 34] we have enough theories to choose from. I think Krüger is making a mistake in using those explanatory theories to draw out an imaginary double bind for clinicians.
Surely clinicians and the rest of us occasionally face double binds in our work and life. Double binds are neither unique to giving uptake nor inherent in giving uptake. I worry that Krüger is closing off the very thing my article is hoping for: the possibility that, by not imposing ready-made theories and interpretations on patients, we may discover new knowledge.
I also worry that Krüger inadvertently stereotypes the patient diagnosed with BPD in just the ways that led me to worry about clinicians' attitudes about BPD in the first place. She imagines that the clinician will be "forced [by the patient] to subscribe simultaneously (albeit subconsciously) to opposing points of view" (2003, 20) She imagines that the clinician is compelled by incomprehensible communications from the patient to "declare the patient insane." 1 Then she imagines that the clinician feels "blame that emanates from the patient" and that the "patient also punishes the clinician" (2003, 20). Krüger seems to assume that the patient is manipulative, wildly erratic in her motivations and needs, and not to be trusted. Krüger is most likely exaggerating the imaginary encounter to make her point, but it is an unfortunate direction to take the problem of giving uptake in excess or when not appropriate.
On the other hand, Krüger is right to point out difficulties in giving uptake properly. Giving uptake is seldom straightforward. I completely agree that we sometimes receive conflicting communications from others. Contradictory, confusing, or inchoate communications make giving uptake difficult. But when this kind of thing happens, we can point it out; we can ask for clarification; we can say why we have reservations about giving uptake to a particular communication. The process of giving uptake need not—in fact, usually should not—conclude in one exchange, or mostly continue as fantasy inside the clinician's mind. When done well, uptake involves a dynamic interplay of exchanges that works toward making more explicit and clearer what each person does and does not mean.
Perhaps it will be useful to remind readers that to say that the body is text is not to say that it is always a text, and to situate body modifications within a framework where the body is understood as a text is not to say that each and every thing we do with and to our bodies is meaningful and requires interpretation. Thus, although it may be the case that, as Sargent quotes Bordo, the body of a "disordered" woman is a text that insists on being read as a cultural statement, I would strongly resist making that an a priori assumption either in interacting with one particular woman or women in general. It may turn out that each and every act of self-injury is a sign requiring interpretation, but we do not know that yet. Even if we did, we ought not to decide in advance what a given self-injurious act means. Likewise, it may turn out that the best way to conceptualize delicate and severe self-injury is on a continuum (Sargent), but we do not know that yet, either. We need to listen more, and listen in a particular way, to BPD patients who self-injure before we can know how to interpret and evaluate and classify the various acts that we now count as self-injury.
--------------------------------------------------------------------------------
Endnote
1. This is a mistake; insanity is a legal, not medical term.
References
Cox, L. 2003. The New Yorker. February 3:66-74.
Foucault, M. 1988. Madness and civilization: A history of insanity in the Age of Reason. Trans. R. Howard. New York: Vintage Books.
Gunderson, J. 2001. Borderline personality disorder: A clinical guide. Washington, D.C.: American Psychiatric Publishing.
Krüger, C. 2003. Self-injury: Symbolic sacrifice/self-assertion renders clinicians helpless. Philosophy, Psychiatry, & Psychology 10:17-21.
Potter, N. 2000. Giving uptake. Social Theory and Practice 26:479-508.
Potter, N. Liberatory psychiatry and an ethics of the in-between. In Ethics of the body: Postconventional challenges. Ed. Shildrick, M., and R. Mykitiuk (forthcoming).
Potter, N. 2002. How can I be trusted? A virtue theory of trustworthiness. New York and Oxford: Rowman-Littlefield.
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