MENTAL DIVERSITY AND MEANINGFUL PSYCHIATRIC DISABILITIES A Dissertation submitted to the Faculty of the Graduate School of Arts and Sciences of Georgetown University in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Philosophy By Laura K. Guidry-Grimes, M.A. Washington, D.C. April 18, 2017 Copyright 2017 by Laura K. Guidry-Grimes All Rights Reserved ii MENTAL DIVERSITY AND MEANINGFUL PSYCHIATRIC DISABILITIES Laura K. Guidry-Grimes, M.A. Dissertation Advisor: Alisa L. Carse, Ph.D. ABSTRACT This dissertation provides a philosophical investigation of key claims arising from the psychiatric user/survivor movement. Users/survivors insist that psychiatric conditions do not necessarily diminish someone’s agency or ability to flourish; rather, they argue that they can find meaningful agential opportunities in virtue of their psychiatric disability. They believe that their form of difference—mental diversity—deserves institutional and interpersonal recognition. This movement therefore challenges standard ways of conceptualizing mental illness, duties of recognition, and what constitutes a valued mode of being. All of these challenges have implications for health care professionals’ ethical obligations and responsibilities in relation to this patient population. I argue that many of the insights from the disability rights movement can help illuminate the philosophical underpinnings of the psychiatric user/survivor movement, though there are differences in the specific normative demands of these two movements. Similar to how the disability rights movement disputes able-bodied norms, user/survivor activism rejects able-minded or “sanist” norms. The movements are not precisely parallel, however, given the distinctive features of psychiatric disabilities. My focus is on value-laden conceptions of mental illness, preemptive paternalism and conflicting claims to epistemic authority, and the tension between respecting “generative madness” on the one hand and avoiding neglect or abandonment of individuals in need on the other. I show that disability modeling accommodates many of the claims from users/survivors, iii including the claim that their disability can be a source of value that deserves recognition. I argue that their demands for recognition of mental diversity will encounter significant obstacles, but those obstacles are not insuperable for all of those represented by user/survivor activism. I illustrate how a psychiatrically disabled mode of being can be cared about because it is meaningful, which leads to prima facie obligations that should shape the clinical encounter. The therapeutic relationship provides a critical opportunity for interpersonal recognition. I argue that shared decision-making can be possible when recovery goals accommodate, within limits, modes of being that the patient cares about in virtue of being meaningful. iv ACKNOWLEDGEMENTS Writing an adequate expression of gratitude has to be one of the most difficult tasks one can attempt. In this case, it is just about impossible. I have been fortunate, beyond my wildest hopes, to have so many people in my corner through the years. The list is actually too long to attempt, and so this acknowledgements page will not achieve all I wish it could. Alisa Carse, Maggie Little, and Madison Powers helped to make Georgetown my academic home. This process was infinitely more rewarding and enjoyable with Alisa, Maggie, and Madison as my committee members. As my advisor, Alisa inspired me and helped me believe in myself even when I struggled. I am also profusely thankful to Carol Taylor, who provided invaluable mentorship as I worked toward becoming a clinical ethicist. Florida State University is where I fell in love with philosophy and first became exposed to the field of bioethics. David McNaughton, John Roberts, Mike Bishop, Aline Kalbian, Carrie Sandahl, Michael Ruse, Martin Kavka, Al Mele, and Charlie Hermes were among the many at FSU who opened doors and made me believe that I could take on a Philosophy PhD. Completing this dissertation required a great deal of understanding from my employers and co- workers at MedStar Washington Hospital Center. I am grateful, more than I can say, to Evan DeRenzo. Evan recruited me for this position, even though she knew it would not be easy with my being in the midst of dissertation work. She protected my dissertation time, even when it was difficult. Evan’s generosity and kindness were key to my finishing this degree. Norine McGrath has always been respectful of my time, supporting me as a clinical ethicist and as a student, and I am deeply indebted. My other colleagues at the Center, Kahlia Kéita, Nikki Glover, and the late Jack Lynch have been so important for making my work life wonderful. Ever since I was a child, my mother has modeled excellence and achievement. She has constantly supported my academic pursuits and professional dreams (even when I wanted to be a performer for a living). There have been times during this dissertation process when I needed assistance with Opal (my canine munchkin), and my mother came to the rescue so many times. For many years to come, I will try to show the depth of my gratitude for all my mother has done. Throughout my life, my father has helped me believe in myself, and he has never ceased to express pride. I am so grateful for the loving support of my father, stepmother, and sisters. My partner and my love, Jamie Watson, spent many hours talking through rough sentences and wrinkly arguments with me, even into the wee hours. Words cannot express how much I value his contributions and everything else he has done as a true partner. There are so many friends I could thank. Elizabeth Victor, Megan Dean, Molly Wilder, Anne Jeffrey, and Colin Hickey have been sounding boards as I worked through bioethical puzzles over the years. I am also grateful to a certain friend from half a life ago, who inspired this whole project. Many Thanks, Laura K. Guidry-Grimes v TABLE OF CONTENTS Introduction ..................................................................................................................................... 1 Chapter One: Distinctive Aims and Challenges of Psychiatric User/Survivor Activism ............... 8 Background on the Psychiatric User/Survivor Movement ........................................................ 11 Prominent User/Survivor Groups .......................................................................................... 12 Key Harms Identified ............................................................................................................ 17 Unifying Activist Aims ......................................................................................................... 19 Psychiatric User/Survivor Activism and the Disability Rights Movement .............................. 24 Aims of the Disability Rights Movement .............................................................................. 25 Divergence between the DRM and User/Survivor Movement .............................................. 27 Philosophical and Ethical Puzzles ............................................................................................. 30 Mental Illness as a Value-Laden Concept ............................................................................. 31 Preemptive Paternalism and Conflicting Claims to Epistemic Authority ............................. 32 Generative Madness and Concerns about Abandonment and Neglect .................................. 34 Methodology and Roadmap ...................................................................................................... 36 Tools of Bioethics and Disability Studies ............................................................................. 37 Chapter Two: Conceptualizing Psychiatric Disability .................................................................. 41 Impairment, Disability, and the Functions of Models ............................................................... 42 Distinction between Impairment and Disability .................................................................... 44 Functions of Disability Models ............................................................................................. 47 Disability Modeling for Psychiatric Conditions? ...................................................................... 53 Competing Disability Models ................................................................................................... 56 Biomedical Models ................................................................................................................ 56 Social Models ........................................................................................................................ 59 Interactionist Modeling for Psychiatric Disabilities: A Promising Hybrid ............................... 63 vi A Growing Spectrum ............................................................................................................. 65 The Search for a Model in the Psychiatric User/Survivor Movement .................................. 68 Interactionist Models of Psychiatric Disability ..................................................................... 70 Implications of Interactionist Modeling for the User/Survivor Movement .............................. 76 Chapter Three: Recognition of Mental Diversity ........................................................................ 79 Philosophical Underpinnings of Recognition Politics .............................................................